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Commentary |
1 Department of Radiology, Section of Musculoskeletal Imaging, Children's Hospital Boston and Harvard Medical School, 300 Longwood Ave., Boston, MA 02115.
Received March 22, 2006; accepted after revision March 24, 2006.
Each month the American Journal of Roentgenology will republish
online one of the 100 most-cited articles from its first century. A
corresponding commentary in the print journal by a contemporary radiologist
will provide a current perspective. For a full list of these articles, see
page 3 of the January 2006 issue of the AJR or go to
www.ajronline.org.
Keywords: child abuse • infants • long-bone fractures • neonates • pediatric imaging • pediatric radiology • subdural hematomas
Among his many distinctions as a pioneer in the burgeoning field of pediatric radiology, John Caffey [1] wrote the first systematic clinical and radiologic study of infants and toddlers with the now well-recognized features of child abuse. In this landmark 1946 AJR article, Caffey reported six children under 2 years old with long-bone fractures and subdural hematomas. Their neurologic symptoms were first reported between the ages of 2 weeks and 10 months (mean age, 5 months), and the age at which fractures were first documented ranged from 6 weeks to 16 months (mean age, 10 months). Injury patterns included various shaft fractures, metaphyseal lesions, and periosteal new bone formation of the upper and lower extremities. There were no skull or rib fractures. There was no history of trauma to explain the findings.
Frederick Silverman [2], a protégé of Caffey and an important contributor to our current understanding of child abuse, drew attention to the work of Ambrose Tardieu, a professor of legal medicine at Faculté de Medicine de Paris from 1861 to 1879. In 1860, nearly a half century before the advent of diagnostic X-rays, Tardieu [3] published an article on the mal-treatment of children that detailed the clinical findings, including the description of fractures. Although a few case reports of fractures in patients with subdural hematomas appeared in the 1930s, 86 years elapsed before Caffey [1] and others [4, 5] documented the radiologic findings. In a sense, the radiographs provided concrete evidence of a phenomenon that could be traced to antiquity [3]. It appears that the radiographic depiction of inflicted injuries brought the notion of abuse to a visual level and made it accessible to the medical community at large. Currently there is extensive and rich literature detailing every facet of child maltreatment, and diagnostic imaging continues to influence our understanding and recognition of this complex disorder.
The importance of Caffey's [1] observations notwithstanding, one might wonder why he failed to make any emphatic statements regarding intentional injury on the part of the caretakers of the children in his 1946 study. According to Silverman [2], Caffey was convinced that traumatic events resulting in subdural hematomas and in skeletal lesions were causally related and most likely reflected "parental malfeasance" [6]. Silverman also noted the care with which Caffey described the circumstances surrounding his case reports. He drew attention to Caffey's comments that "recognized injuries may be denied by mothers and nurses because injury to an infant implies negligence on the part of its caretaker," and furthermore, "In one of the cases, the infant was clearly unwanted by both parents, and this raised the question of intentional ill-treatment of the infant" [1]. Silverman thought that Caffey did not go further because "he was concerned about possible legal repercussions" [6]. This reluctance to suggest that a child has been injured at the hands of a caretaker, despite compelling evidence, remains a powerful deterrent to mandated reporting and appropriate adjudication of cases of suspected abuse [7].
Great progress has been made in our understanding of the spectrum of inflicted injuries in children, and diagnostic imaging has been instrumental in this process. The growing list of entities that may masquerade as abuse continues to receive much attention within the medical realm and in various legal arenas. The intense litigation surrounding cases of suspected abuse along with the difficulties encountered by physicians in an adversarial courtroom setting may present a daunting challenge to well-intentioned medical witnesses.
Much can be learned from Caffey's [1] article, not only in substance but also in what it says about his scholarship. Thorne Griscom [8], an avid student of the history of pediatric radiology, noted that Caffey was "supremely organized in his approach to pediatric radiology. He focused on the diagnostic challenge and gave it his undivided attention." Radiology will continue to play a central role in the diagnosis of child abuse and its simulators. Caffey's seminal article will remain a primer for all those who wish to learn the history and contribute to our future understanding and management of this important public heath concern.
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