[Music]

[The U.S. Department of Health, Education, and Welfare, Public Health Service, presents T - 1899, V - 1899, MCMLXIX]

[A National Medical Audiovisual Center Production]

[Clinical Pathology Series, A Cooperative Project]

[Emory University School of Medicine and National Medical Audiovisual Center]

[Forensic Medicine Outlines, The Battered Child]

[Part 1]

[Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

[Dr. Helpern:] I'd like to discuss the problem of the battered child or the battered child syndrome, 

as it is sometimes called. 

This subject is extremely important to forensic pathologists 

for the reason that they may be the first in line with the investigation 

to discover this possibility. 

Of course the clinician, the pediatrician, the general practitioner, 

also has a lot of responsibility,

because in many of these cases the violence has been repetitive,

and at some time the victim has been taken to the clinic and has been exposed to clinical observation,

and the doctor does have a chance, if he is on the alert, 

to recognize the possibility that the injuries which a child manifests,

and the explanation for which is given by a parent or guardian, 

is hardly compatible with the extent of the injury. 

And I thought today we might go into the problem as the pathologist may encounter it. 

It's very important in all forensic work to listen to the history,

but not necessarily to buy the history that is offered 

by a parent or guardian with regard to how injuries are sustained.

And to me it's perfectly amazing how in some of the cases of very flagrant violence,

the explanation of the guardian or the parent of the infant

that it fell from the sofa onto the floor or that it kept falling down the stairs or this or that,

is accepted as an explanation and nothing more is done about it. 

Now, this subject is not new. 

We have observed instances of abused and battered children that have died from repetitive violence. 

This is an old subject, 

but recently it has gotten a lot of notice in the public press and in scientific publications. 

But I want to point out and emphasize that we have observed these cases for a long time,

and it is the responsibility of the physician, and also the pathologist when he encounters a case of this sort,

to notify the authorities, the Department of Public Welfare, the Police Department, 

so that an adequate investigation can be made. 

Physicians sometimes shy away from this responsibility

with the excuse that they don't want to get involved,

that perhaps the families of the infant might bring suit. 

But when a physician calls attention to an injury of a suspicious character or when the pathologist reports the violent character of a death, 

he is not accusing anybody, he is merely exposing a situation. 

The investigation later may point to a suspect and to a perpetrator but the doctor doesn't name perpetrators. He's not concerned with that. 

He's concerned with exposing the situation as he finds it and bringing this to the attention of the authorities. 

I think this is very important to bear in mind. 

There are laws now which require the physician to do this,

but in the past he always had this responsibility as a physician 

to report any death from suspicious violence or any assault,

or any case in which there is any suspicion at all 

that the violence might have been inflicted or resulted 

from the assaultive act of another person. 

I think we doctors sometimes tend to rationalize 

in order to not have the job of later on coming forward 

and having to present the findings in a court if this is necessary. 

But the idea that you endanger yourself by exposing these things, this is not so at all. 

You're not accusing anybody. 

You're not naming anybody. 

You're merely calling attention to a situation with regard to an injured infant

or in the case of a pathologist, to a dead infant. 

Now when these cases are discovered, they have to be reported,

and a certain amount of activity and awareness has to be, 

the pathologist has to be aware of this responsibility and do something about it at the time,

and not just simply accumulate these cases in an anatomical diagnosis,

or just simply place it on a death certificate. 

Death certificates get classified, 

but ordinarily the police department does not comb through the death certificates 

to see whether there are any cases of possible violence. 

That's something that the doctor has to do, 

the pathologist has to do. 

And this is a very important practical point because sometimes these cases, 

which require very careful investigation, 

get lost in the shuffle. 

Now I would like in the time that we have 

to point up some of the cases and to indicate how variable they are, 

how some are quite obvious, 

on the other hand some are discovered simply through the routine process 

of performing a postmortem examination,

including an autopsy in that examination when an infant is found dead or where an infant dies suddenly. 

And I think one of the interesting byproducts of the study on infant death, 

most of which yet have not provided an adequate explanation for the death; 

among these hundreds of cases, we do discover a few cases of violent death 

where this was not suspected during life,

or actually when the case was brought to the attention of the authorities. 

And this is one important byproduct, one might say, 

of the infant death studies which are being carried out in so many jurisdictions,

trying to discover the various factors that are responsible 

for the crib deaths and deaths of that type. 

Now I'd like to show a few cases. 

The first case I want to show is that of an infant that was presented 

to our office as an unexpected death of an apparently healthy infant,

and at first-hand it was believed to be a crib death,

and the child was found dead in the crib in the usual facedown position.

And outwardly there were no signs to suggest violence. 

This is a photograph of the face,

and there are no bruises and ecchymosis that one sometimes encounters in the battered child syndrome.

There's a little secretion coming from the nostril,

which might be misleading and lead the unwary pathologist to a conclusion 

that this child had an upper respiratory infection which it might also have in addition. 

And finding an upper respiratory infection does not rule out the possibility of violence in a particular case. 

Now this is a side view. 

There are a few small abrasions on the face but you notice there's no ecchymotic discoloration, 

there are no bruises that one sees on the outside. 

And yet when the scalp was reflected, 

you have this very severe injury 

which actually did produce a boggy swelling of the scalp,

which was more evident after the scalp was reflected then before,

but there's terrific hemorrhage here in the galeal portion of the scalp,

and also in the pericranium. 

And there are also fractures of the skull in this case,

with intracranial hemorrhage of a traumatic character. 

Now the explanation was offered in this case that the child might have fallen off a couch 

which was about a foot and a half off the floor,

and this explanation was not adequate,

and subsequently one of the parents in a situation such as this,

not infrequently the child is living with its natural parent 

and also with a stepparent or with a person who is consorting with the true parent.

The children may be by a first marriage and the father or the mother then takes on another mate

and the children become somewhat of an annoyance because of crying. 

There are many people who are not emotionally able to bring up children

and haven't got any patience at all to look after a child in the way that it should be, 

when it cries,

or when it becomes irritating to the parent or to the guardian. 

There's a whole variety of situations that we find in these cases. 

Most commonly you find a person having children sometimes born out of wedlock, 

now exposed to the anger and actions 

of a new companion of the natural parent. 

And you find situations, too, in which the parents, 

or one, the father for example, with a lot of small children, 

marries another woman or takes up with another woman whom he may not marry, 

and these children, most children have a sort of an instinctive ability to get along well with people. 

I mean they behave because they find it very wise, 

I mean in order to avoid injury and corporal punishment they do give in,

and they do conform to what the new guardian may want them to do. 

But the rebellious child, and it may be rebellious because it just isn't as smart as the other children, 

the rebellious child is always in great peril and may suffer unduly, 

whereas the other children who are docile and who do not offer any problem in discipline 

may be very well taken care of. 

There's some very curious situations that develop during the investigation of these cases. 

Now, the next case that I'd like to show is another example 

of what was thought to have been a crib death, an infant found dead. 

The child had been left in the care of a sitter, 

and the mother of this child had gone off with a new boyfriend,

and when she came back the child was found dead. 

The sitter indicated that she had fed the child

and apparently had done all the right things by it. 

There was still another person living in this house. 

This was a small apartment occupied by a whole group of people,

and all that the sitter could recall was that the child had been crying,

and when she went into the kitchen to warm up the bottle, she put a big pacifier in the child's mouth

and when she came back the pacifier was missing. 

And so was the particular person who had been seemingly playing with the child while she was, 

while the sitter was in the kitchen. 

This was a very strange situation too because there was quite a background of narcotic addiction. 

The mother had taken up with a person in the narcotics business, 

a pusher who apparently had been very successful 

so that the mother was extremely well-dressed. 

The babysitter was paid off with shots of heroin. 

In other words, her employment was paid for by providing heroin shots so a very sordid situation. 

Now when the autopsy was started, 

there was nothing externally to see,

but when the pathologist got into the region of the neck after removing the throat, 

here this is all the front portion, the skin is lifted up, 

you can see coming down through the throat a large nipple.

This is the pacifier pushed down into the throat. 

Now the child couldn't possibly have swallowed this. 

There was a big flange on the nipple and this was evidently pushed down,

and it was a very difficult type of case to investigate. 

Now if you simply do an autopsy on the body and take out the heart and the lungs and all that and just go through the routine, 

this would very easily be overlooked. 

To find things like this you really have to get into the throat 

and have an ample exposure, and then things begin to appear. 

So this was a case of homicide in which the nipple of the pacifier 

was forced down into the baby's throat for reasons which are very, 

I mean what prompted the perpetrator to do this is one of those very difficult things to answer. 

Here's another type of case that is very suggestive to start with. 

This is a child that is found dead by the parents and when one gets a history, 

that is when the medical investigator goes to the home

he gets a history that this child was a feeding problem, 

cried a great deal, had had the sniffles and this, that, and the other thing. 

And if you're gullible you can sort of write a case like this off 

as a case of acute gastrointestinal auto-intoxication,

or whatever other funny things appear on death certificates in various parts of the country. 

This type of case is not routinely investigated, unfortunately. 

But these cases should all be subjected to a very searching type of autopsy,

because frequently the initial story, if one isn't too critical and one is gullible, 

may lead to a certification of an inadequate sort, 

sometimes done over the telephone by instructions from the coroner 

to the local doctor in the community who might be called upon to issue the certificate. 

And some physicians will issue a certificate when they're requested to do so by someone in authority. 

Other physicians are more independent and feel that they don't have the right to do that,

and that the circumstances and their findings or their impressions 

do not entitle them to write this case off as a natural death 

simply because they're instructed to do so by the coroner in the local area. 

Now you notice this child is rather poorly nourished and the child, 

when one turns it over, one sees some very interesting findings,

and not so much on the front of the body but on the back there are these welts, of varying age. 

This child apparently had been beaten. 

One not infrequently finds welts like this over the region of the genitalia.

The child that urinates in bed and is considered one that needs disciplinary action

and sometimes the beating is inflicted over the genitalia, 

with the idea that you might do with a puppy, to sort of housebreak the infant. 

And I want to show you some more of these things. 

Now there was a small bruise around the temple of this child, which wasn't too evident in that photograph,

but again when the scalp was reflected there was very extensive injury here and this is all rather fresh, 

the blood here is quite fresh-looking and not hemolyzed,

and there's also a fracture of the skull in this case, 

with an intracranial injury. 

And here's the skull fracture that you can see very well on the inner surface of the calvarium. 

And as many of these fractures tend to be, 

they radiate down from the parietal boss, 

and there's quite a lot of hemorrhage in the surrounding tissue in the bone. 

Now there are indications here that this was not all one injury, 

but this was a series of repetitive injuries. 

And the remarkable thing is how these infants 

and how these young children can withstand the amount of trauma that they receive. 

So that when they die you sometimes can't pinpoint the particular injury 

which was responsible entirely for the cause of death. 

Death is due to the effects of the combination of the injuries. 

The cause of death in cases like this is complex, 

and you can't say that this injury did it or that injury did it. 

Not infrequently when one is examined, cross-examined, 

in court and testifying in a case like this, 

the lawyer representing the defendant will say, now which injury killed the child? 

Well, it isn't one injury that killed the child. 

It's the combination of all the injuries. 

And you cannot pinpoint and you should not pinpoint a particular injury 

just to provide an answer which is unanswerable in a particular case. 

Now this is the picture of the inside of the skull. 

There's a fracture right here, you can see it right now very well. 

And this is the posterior fossa and the foramen magnum is around here. 

Again you'll notice this tremendous amount of surrounding hemorrhage. 

And here is a picture of the brain showing very severe contusion and hemorrhage 

on the surface and in the substance. 

And to get this effect in an infant brain, 

does require a great deal of trauma so that one can say in this case that the brain injury, 

the intracranial injury, was the cause of death

and didn't require all the other injuries. 

This is rather an unusual type of finding,

because when infants have fractured skulls one doesn't see, as a rule, the extensive brain contusion 

that one would see, for example, in an adult brain with a corresponding type of injury.

And one of the other findings in this case 

is indicative of prior trauma that this infant received, 

You can see in the ribs, these are the costachondral junctions, 

but in the bony portion of the rib you can see these calluses, 

these cartilaginous calluses representing healing of old rib fractures,

and this is a very common type of finding. 

One does see in the skeletal system evidence of old healing injuries. 

Now sometimes these are observed by the clinician, 

by the physician in the clinic or in private practice, 

and x-rays may be taken, and this material has to be examined, 

interpreted very carefully and the pattern of the findings is suggestive of prior trauma, 

and should immediately bring up the possibility 

that this is a child that is being abused. 

Again, too often an explanation which the parents 

or the guardians offer about the child 

having been falling or running around and being overactive 

is a rather unsatisfactory one for the extent of the injury. 

Children fall a great deal and they don't injure themselves very often in falling,

but they are very easily injured when they are battered 

by someone else who is inflicting the trauma. 

Now this is another case but it shows a very, 

it's a good example of the type of bone injury that you see in the battered child. 

This is an infant that died of multiple injuries,

including injuries to the long bones which were not evident 

from the external appearance of the limb,

but we had x-rayed this child and found evidence of this,

and then removed the humerus. 

You can see the ossification centered in the head there,

and here's the shaft and here is a fracture, recent, undergoing some degree of repair

with subperiosteal hemorrhage undergoing organization. 

It's rather important to recognize this as a fracture, 

and not as some dyscrasia or some variation of scurvy. 

I've had bones like this described as scurvy on the basis of subperiosteal hemorrhage,

which obviously is in relation to the fracture of the cortex 

and the shaft of this long bone. 

These heal rather rapidly and the callus which is initially laid down 

is not ossified but after a period of time,

the lime-salts are deposited and one recognizes this for what it is. 

But I thought you'd like to see an example of a long bone in a battered child. 

I might say that if you're doing an autopsy like this,

you can remove a bone and examine it,

and this is one time when you can go beyond the conventional incisions. 

And I think we'll continue this discussion in the next presentation.

[Music]

[Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

[Forensic Medicine Outlines, The Battered Child]

[Clinical Pathology Series, A Cooperative Project]

[The End, T - 1899, V - 1899, MCMLXIX]

[Clinical Pathology Series, A Cooperative Project]

[Emory University School of Medicine and National Medical Audiovisual Center]

[Forensic Medicine Outlines, The Battered Child]

[Part 2]

[Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

I should like to continue the discussion of the battered child syndrome

with a few more illustrated cases. 

There's a great variety of findings in some of these. 

Most of them are evident, as I indicated from circumstances and external findings,

but as I also pointed out, some of them show no external signs of traumatic injury 

and the initial story can be very misleading and very similar to the story one gets 

in the crib death where the parent or guardian simply find the infant dead in the morning 

and rush the body to the hospital. 

And the doctor and the clinic may or may not suspect something,

but in DOA cases generally the admitting doctor feels 

he doesn't have that responsibility, which he doesn't, 

and he reports the death to the medical examiner's office 

as a so-called DOA and this can be anything

once the body has been taken from the scene. 

Many parents in finding a child dead, not wanting to recognize that it is dead, 

will pick the body up and rush with it to the clinic. 

Sometimes it may even arrive after rigor mortis has set in 

and obvious death is noticed. 

Sometimes the admitting physician will record this 

and sometimes he doesn't do this in the pressure of other work 

that he has to do. 

Now this next example that I want to show you is an infant 

that was brought in from one of the outlying boroughs. 

It was found dead. 

There was a history, which our medical investigator obtained, 

that this child had fallen a short distance,

and he wasn't satisfied with the history that the family gave him 

and ordered the body removed to the mortuary for a routine autopsy. 

And one notices, for example, a small abrasion, this is fairly fresh, 

on the forehead and the child is malnourished. 

It's eight months of age. 

And then you see some areas of depigmentation on the left knee and this was explained away by the family 

as a slight scald that the child had received and you wonder how that happened.

And then if you look at the back of the child you notice that there's very extensive scalding 

which would indicate that the child had been dipped into very hot water. 

And this is an old lesion, 

you see it's completely epithelialized with non-pigmented skin. 

At the time this was not considered suspicious when this child was treated in the hospital and it should have been but it wasn't 

and the police were not notified of this particular incident. 

There's some bruising of the buttocks, 

and a very easy way to demonstrate injuries in the buttock fat 

is to incise through the subcutaneous fat. 

And one not infrequently finds bruises 

indicative of whipping that the child might have received. 

Now, a very characteristic injury that one sees in the battered child, 

which is not evident from the outside, and this often results from blows to the abdomen, 

sometimes the child may be punched and sometimes the child may be thrown. 

All sorts of violence are exerted on these infants. 

This is a case in which the liver shows a fairly characteristic type of injury, 

a longitudinal laceration between the lobes with considerable bruising of this lower margin here 

and the liver is almost cracked in two,

and there is blood in between the edges. 

Now this is an injury that occurred not at the time of death 

but sometime before because it shows some evidence of repair. 

The next slide shows the lungs of this infant, 

which also show very extensive contusion, 

suggesting that it had been thrown about and sometimes these infants are picked up 

and physically thrown against hard projecting objects, 

and this type of contusion of the lung with a large subpleural [?] filled with blood 

is not an uncommon type of injury 

and very evident when the organs are examined. 

And with regard to the liver injury, if one takes it in the hand 

and gently separates the edges after taking some of the tissue 

from microscopic examination, 

you can see that this laceration which extends deeply into the parynchema

of the liver from the anterior surface 

in the region of the interlobar fissure, 

has already produced a reparative reaction. 

There's a little bit of traumatic infarction in the margin 

and there's organization of this blood clot indicative of a process 

that has been there for some time. 

And then there are also some intraparynchemal tears 

due to the very severe distortion which the liver has undergone. 

And another injury that one sees as the result of a blunt force impact over the right upper quadrant, 

the liver is pressed against the right adrenal. 

The right adrenal is very vulnerable to contusion. 

And here you have a contused adrenal 

with a very thick hemorrhage in the medullary portion. 

Outwardly this adrenal merely showed swelling 

and when it was incised this very severe hemorrhage was found, 

all adding to the shock of the injuries and to be included in the cause of death. 

Now, in connection with the liver injuries, blunt force applied to the abdomen after death 

can also produce injury 

and sometimes an infant is brought in 

and the true nature of the case is not recognized in the hospital 

and very violent attempts at resuscitation are made. 

And as sometimes happens in adults too, these attempts at resuscitation can produce postmortem injuries 

which in their pattern are very much like the antemortem injuries 

and sometimes they are difficult to tell apart, 

except that in the postmortem cases, 

one does find a lack of reaction in the margins. 

And this is a case in which a child, a young child, 

was brought into the hospital without any external sign of injury. 

It was thought that it had passed out, and in the attempts to resuscitate this child, 

artificial respiration and resuscitative measures were taken 

by a number of persons, 

and with considerable violence applied to the region of the heart. 

This was sort of a closed-cardiac massage with a little bit of extension 

into the epigastrium. 

And while the heart didn't show any contusion, 

there was this extensive laceration, this, liver in this case, 

very much like the actual laceration I showed you in the other case, 

but without any reaction at all, 

and this was borne out by the microscopic studies. 

But if one isn't careful, one can confuse this with a true injury. 

Now there's also some passive outpouring of blood 

from the large vessels which are torn in a case of this sort. 

And on the posterior surface, 

again you can see the rather bloodless appearance of these tears 

and the lack of reaction of this type of postmortem injury. 

So that these attempts at resuscitation of a dead child may confuse the issue, 

especially when these are made in cases of a true and actually battered child. 

I recall one case I was asked to review that happened in another state. 

It was one in which a child was brought into the hospital in shock, 

in a moribund condition. 

And where the resident who was on duty administered artificial respiration 

and closed cardiac massage. 

When the autopsy was done, it was found that there was a hemopericardium, 

a contusion of the auricular appendage and a rupture, 

delayed rupture of this contusion. 

But what made it complicated was the fact that the manipulation had occurred after death, 

and whether the amount of blood in the pericardium 

was increased by this procedure or not was not determined. 

Microscopically one could actually see that the rupture was antemortem. 

There was a reactive lesion around the contusion. 

This child had been picked up and thrown against a hard, pointed object 

and had fractured ribs and a contused heart with a delayed rupture. 

And in that case the parents, the mother and the stepfather, 

were brought to the district attorney's office for questioning. 

They admitted disciplining the child. 

They believed in the old adage of spare the rod and spoil the child 

but they didn't quite know how to handle the situation 

when the rod was overused. 

They used a paddle on this particular child and the infant showed evidence of having been paddled 

and the stepfather said well, that's the way he was brought up. 

There was reason to believe that the violence had been inflicted 

by the mother rather than by the stepfather. 

The first husband of the mother, the father of the child, stated that he got himself divorced from this woman 

because she was very vigorous and he was getting tired 

of all the corporal punishment that he was receiving. 

So they had reason to believe that in that case, 

the injuries might have been inflicted by the true parent 

rather than by the stepfather. 

But these are difficult cases sometimes to handle because you don't know what the intent is 

and just to define how much corporal punishment a parent can administer,

and the question of the threshold of patience in handling children. 

It's not all mother love or parental affection. 

One thing one learns in a medical examiner's office, 

that it's always a case of mother love and father love. 

Looking after all these infants, the remarkable thing is 

how some of these infants and children actually survive the perils 

and hazards of growing up within their own household. 

Now this is a rather interesting case. 

It's an infant of eight months that was found unconscious 

and taken to the hospital where it died shortly thereafter. 

And if one examines the face you can see bite marks on the nose, blunt force injuries on the head. 

This infant was assaulted by a two year old sibling 

who attacked it with a heavy toy 

and also bit it, evidently resenting its arrival and presence in the family. 

This is a problem, I think, that families do have to consider,

the attitude of an older child toward the new arrival. 

And we had a very interesting case not too long ago of a three months old infant, 

or two and a half months old infant, 

whose head was battered very much like the one you just saw. 

The mother was questioned and she said she allowed the infant 

to remain in the room with two older children. 

The oldest one was four years and the one in between was a one year old. 

One thought that the one year old couldn't have done this, 

and that it was probably the four year old. 

The mother brought the four year old and the one year old down to the office. 

The four year old was a perfectly placid child, 

just sat where you placed it, wasn't interested in what was going on. 

But the one year old was an overactive infant, rather child, 

and very vigorous, very active, and obviously was the one 

that was responsible because it was brought into my office 

by our receptionist and I was told, 

"Dr. Helpern, I want you to meet the youngest perpetrator of a homicide we've had in our experience." 

And she brought in this one year old child, walked him into the office 

and he became very active and climbed over everything 

and you could see how he could very easily batter his baby sibling 

with a toy that was the nature that one hit the pegs with a hammer, you see. 

So the child had the hammer and the pegs and all he had to do was let go 

and probably considered the new infant somewhat like a doll 

and exercised this destructive action on it. 

One does see very bizarre cases and they're not the ones we're worried about. 

I mean we try to prevent that sort of thing. 

But at least they're understood 

and they're subject to handling by the authorities. 

But the cases in which the violence is inflicted by older people, 

these are the ones that really have to be looked into 

and these infants protected from those who are supposed to be guardians. 

Now of course to leave a child exposed to the action of an older child 

is also a sign of irresponsibility, 

but in crowded families one can see how this can happen. 

The mother goes out on an errand and leaves the children at home 

and this type of assault sometimes takes place. 

Now this is the, this last case in which the child was battered by the two year old sibling, 

this is the extensive skull fracture that was produced with the blunt object, 

with the object that was used to strike the baby's head. 

You see this fracture of the parietal bone 

with some depression of the fragments 

and a lot of hemorrhage into the tissues. 

The child died from these injuries and the shock of the injuries. 

Now this is a case which I photographed to show welts on the body 

and these should be evident to any physician who examines the case. 

They very often go across the buttock.

and the buttock has a sort of dusty color which is somewhat difficult

to see through the pigmented skin, but incision into the buttock tissues

will readily determine or confirm the presence of severe bruises.

Many of these cases are brought into the admitting rooms of the hospitals 

and the resident physicians on duty should certainly consider the possibility of a battered child

when an infant is in shock, and not accept the explanations 

which are offered by the parents or the guardians. 

They should alert the Department of Public Welfare 

and they should alert the police department, 

not that they are accusing anybody, as I said before, 

but to bring the situation to light so that it can be promptly investigated. 

And here you see these stripe-like welts from beating on the extremities 

which represents the effects of corporal punishment that many people inflict on children. 

Now this is a very severe case that goes back many years ago. 

This is a four year old child, one of five children, living with a stepmother. 

And actually the person, this woman was not married to the father whose first wife had died, 

the mother of the children had died. 

Four of the children were exceedingly well-taken care of. 

They were well-dressed and well... 

But they were docile and they apparently were smart enough to keep away from the temper of the mother, 

the stepmother or the step-guardian 

or whatever you want to call her, legally. 

This little boy was somewhat defiant 

and in order to be punished, apparently he received the punishment for all the children. 

I mean he was really the whipping boy in this case. 

And he shows very severe injuries. 

What this woman used to do to him, he was in the habit of touching things 

that she didn't want him to touch 

and she would take his hands and put them over the flame of a gas stove. 

And he has these very severe burns you see which are all festered and infected. 

And then he has very extensive evidence of whipping, 

I mean the external appearance. 

How this could go on so long, this child had been seen from time to time by, 

taken to clinics and so on,

but the simple explanation, well, the child burned itself. 

Well how could a child burn itself by its own actions? 

And I think that we doctors tend to be a little too gullible and to accept explanations which sound plausible at the time 

but what we are really doing is rationalizing a situation so that we don't do all the things that we're supposed to do 

based on our findings rather than on the story. 

And most of these stories that we get are very unsatisfactory 

and provide an inadequate explanation of what has really happened. 

And it's up to the doctors to really stimulate a little activity 

on the part of the investigating agencies, and they want to do this, 

but they can't do it unless they're alerted to these situations. 

And too often there's a lot of passivity on the part of the persons 

who have an opportunity of doing this 

and this is one of the responsibilities

of the forensic pathologist in completing his work. 

It's all right to determine the cause of death and photograph and catalogue these findings but one has to do something about it, 

just like one has to do something about it 

when we discover a case of carbon monoxide poisoning. 

And here's the other hand, these granulating wounds, terrific amount of injury 

and how the child survived as long as he did is really beyond belief. 

Those are the cases I wanted to show. 

There are many other points that one can make.

Not infrequently the roentgenologist is the first one 

to pick up the multiple fractures in a healing state.

Sometimes the fracture, in some of these children the arms are pulled 

and the child is swung by the arm 

and there may be a separation of the epenthesis from the [?] of the bone. 

Initially, since the cartilage doesn't show up in the x-ray, no real finding is noted in the x-ray, 

but after a relatively short period of time the reparative process sets in 

and the hemorrhage begins to undergo ossification, new bone is laid down. 

There have been instances, you know, where this process

was mistaken for a bone tumor. 

But I think most roentgenologists now and most clinicians, pediatricians and pathologists, 

are aware of this finding. 

And if you're in doubt and you have an x-ray available in the autopsy room, 

then I think it's justifiable to make an incision over the bone 

and to examine that bone in situ and to remove whatever portions are necessary. 

The skeletal manifestations are extremely interesting, 

the multiple rib fractures that are sometimes sustained 

when the infant is thrown against the corner of a hard object like a chest, 

and the impact against the chest will crack the ribs in a line. 

And then the reparative process will set in. 

If you see these children immediately after the injury is inflicted, 

then the fractures are not so evident as they are when the callus formation develops. 

But certainly an autopsy of the ribs and the skeletal system, the whole skeletal system, 

should be very carefully explored and sections taken for, 

microscopic sections taken for collaboration. 

I think this will complete our discussion today.

[Music]

[Forensic Medicine Outlines, Milton Helpern, M.D., Chief Medical Examiner, The City of New York]

[Forensic Medicine Outlines, The Battered Child]

[Clinical Pathology Series, A Cooperative Project]

[The End, T - 1899, V - 1899, MCMLXIX]