Thursday, December 6, 2012
Since the title of this blog is “Oxygen the Spark of Life” a reader might well ask why I am addressing the subject of child abuse. In all my posts I have tried to show that normal brain activity depends on normal energy metabolism induced by efficient oxidation. It is obvious that child abuse can be simply a lack of love and we know that people are capable of cruelty but I have had an unusual experience with child abuse. The nature of the extreme cruelty is hard to explain as coming from a parent with a normal brain function. I am going to recount the history of three unusual cases. They were so awful that it resulted in a symposium at Cleveland Clinic Foundation where every member of the many public organizations in the city dealing with children’s welfare were invited. Many years later, I met a woman that told me that it had led to the establishment of the “hotline” that operates in Cleveland today. They all happened so many years ago that identification would be impossible. Perhaps the most tragic case was Charlie who was brought for medical consultation “to explain all those scars on his body”. The point is that the correct nature of the cause of the injuries is never given. It is “this strange disease” or “he fell off a wall” etc. So a physician has to be a detective as well as a sympathetic listener. It turned out that the real cause of Charlie’s scars was repeated cigarette burns perpetrated by his mother. This has been reported in other cases. I imagine that it is “you do that again and I will punish you with another burn”! It comes from the mind of a parent under extreme stress, especially as the father had the nickname ”Killer”. Then there was Vicki, aged four, who was admitted to the hospital with an obvious case of Kwashiorkor, the typical appearance of protein starvation seen today in children of third world countries. Vicki quickly began to flourish, even with “hospital food” and it turned out that it was a case of attempted homicidal starvation. Although this could not be proved, the mother was ordered to appear with the child at regular intervals. Each time that she made an appearance the child was clothed in a new outfit, each one being of a different color. One day the child appeared with three bruises on her forehead and this was explained by a fall. I must add here that all this was before the Child Abuse law was established in Ohio. At that time it was necessary only to report a suspicion to the police. Later, Vicki was brought into the emergency room in coma and was passed immediately to neurosurgery where the brain tissue was found to be abnormal in appearance and substance. When she died, nothing could be proved but I suspect that she was smothered. The last case I want to describe was a 6-month old infant referred by a pediatrician who had found an enlarged liver in the child. He was scheduled for liver biopsy but with TLC from the nurses he began to sit up by himself for the first time and to my great surprise, I found that the enlarged liver could no longer be felt. I cancelled the biopsy and told the mother what the findings were and that she would need to follow up with the pediatrician. As I was reporting to her, there was a sudden and dramatic dilatation of her pupils. I became suspicious that she was on the verge of a nervous breakdown and wrote to the pediatrician asking him to watch out for possible child abuse. The mother was referred to a psychiatrist who reported that she was perfectly normal. A month or two later, this child was in an emergency room with a skull fracture, still accepted as “an accident”. The next event proved the underlying truth when the child was found drowned in a bath tub. I later received a letter from the pediatrician telling me of the final event and adding, “ I wonder how we could have prevented this”? I was unable to explain how something as important to an infant as TLC could rapidly lead to a return of an enlarged liver to normal. It did, however, lead me toward the importance of “mind over matter” in consideration of health and disease. Had the simple charm of loving care turned on the placebo effect? Doctors are trained to accept the complaints of a patient and at this relatively early era in mid 20th century, child abuse was not as well known as it is today. Other pediatricians thought that I was cruel and unsympathetic, reflected by the presence of only three or four pediatricians at the symposium. I have suggested in previous articles and papers that murder can occur in blind rage (seeing red), even on the spur of the moment. A crime can be accepted in Ohio as “temporary insanity” if it can be proved that the criminal “knows what he is doing but is powerless to stop himself from doing it”. This, totally different from cold blooded planned crime, was illustrated very well by Dostoyevsky in his novel, “Crime and Punishment”. The trouble is that it is virtually impossible to prove. In the case of child abuse, the abusive actions often occur impulsively and seem to be well beyond the powers of reason. The extraordinary love of motherhood is an icon of human behavior. I hypothesize that the brain of an abusing parent is biochemically abnormal and the child, in some way, irritates her/him to release a physical action known to be wrong, but beyond the power of reason. Although child abusers, like wife abusers, are more commonly from the lower socioeconomic members of society, it is certainly not confined to them. Alcohol and/or poor diet may well enter the picture in many cases, thus introducing biochemical changes that cause excessive irritability that overwhelms the power of reason. For this to be explored and researched, it would be necessary to accept the possibility. Our society and our medical thinking is very far from that.