Abstract
We present an old case, from the year 1928, of a girl who, as an 18-month-old, had ingested a small amount of lye, and over time oesophageal stenosis had developed. However, her parents had not taken her to hospital until 4 months after the event, after an episode of bloody vomiting. She spent the remaining time of her life in the hospital, where she died as a 3-year-old. Her parents did not visit once during that time. After the autopsy, the opinion about the cause and mechanism of death had five steps: the immediate cause of death was purulent pneumonia, which was a complication of small pox and severe undernourishment; the severe undernourishment was the consequence of a narrowed part of the oesophagus; this developed due to the ingestion of the corrosive agent; and it remained uncertain whether the ingestion of the corrosive agent was accidental or homicidal in manner. The presented case could be an example of possible child maltreatment and neglect in rural parts of society, from almost 90 year ago; at the time these cases were not recognized and treated as they would be today. This is also an example of how the forensic pathologist, via the conclusion about the cause of death, highlighted the parents' carelessness and neglect of the child.
Keywords
Introduction
The case that we present here may be an example of possible child maltreatment and neglect, from almost 90 years ago. At the time of the event, this was not recognized and treated as it would be today.
During his professional life at the Institute of Forensic Medicine, part of the School of Medicine at the University of Belgrade, Professor Milovan Milovanović (1884–1948) stored numerous forensic specimens collected since the end of the 19th century. He eventually founded a small museum as a teaching room for the students. 1
Some of the museum specimens are hiding intriguing stories.
The case
Museum reference
Museum specimen M No. 360 is a jar (Figure 1) containing a girl's head, attached to which is a label with the following text: “L No 795, M No 360. Cicatrices faciei post intoxic. cum NaOH… Belgrade, Jun 13th, 1928.” (Figure 1). The scars due to skin burns from the chemical lye are visible on the right cheek, the upper lip and around the mouth (Figure 1). By virtue of the museum reference, this case has been identified in the record-keeping journal for the year 1928 as forensic case No. 187. In the Institute's archive, there is also the autopsy record concerning this case.
(a) Label of the museum specimen M No. 360. (b) Museum specimen: the jar containing the head of a girl. (c) Closer aspect of the girl's head. Note the shallow scar on the right cheek and the upper lip due to lye chemical skin burns.
Case history
In addition to general data about the deceased, the autopsy record, handwritten by Professor Milovanović, contains a heading with information concerning the circumstances of death and the medical history of the deceased (Figure 2). The deceased was a 3-year-old girl, who died in the Paediatric Ward of the General State Hospital in Belgrade. The little girl was born and lived in an isolated village in a rural area. In December 1926, as an 18-month-old, the girl had ingested a small amount of lye, and over time oesophageal stenosis had developed. However, her parents had not taken her to hospital until four months after the event, following bloody vomiting. She had been hospitalized for 3 months, from April to July 1927. It is not known what happened to the girl in the following three months. The child spent the time from 26 September 1927 until her death on 11 June 1928 in hospital in Belgrade. Oesophageal dilatation by bougienage was attempted several times. In hospital, the child had caught small pox, and subsequently developed a lung infection. During the 9 months the girl spent in the hospital, her parents did not visited her even once.
The first page of the original autopsy report: the forensic case No 187 from the year 1928 (handwritten Serbian Cyrillic letters).
Autopsy record
The length of the body was 91 cm and the child was “malnourished”. Professor Milovanović had minutely described the shallow scar on the right side of the face. The tongue was furred and the tonsils were swollen. The wall of the middle third of the oesophagus was thicker and firmer, with scar tissue; the lumen of this part of the oesophagus was narrowed and with livid mucous membrane. The airways were filled with purulent mucus. The lungs were changed by purulent inflammation, and the left half of the pleural cavity contained about 300 ml of purulent liquid.
Cause of death
Professor Milovanović divided his opinion about the cause and mechanism of death into five parts: “I. The cause of death was purulent pneumonia…” as the “II… Complication of the small pox and… severe undernourishment…”. “III. Severe undernourishment was the consequence of… the narrowed part of oesophagus…” which “IV… Developed due to corrosive agent ingestion…”, and he was uncertain if the “V… Corrosive agent ingestion was accidental or homicidal in manner.”
Discussion
Corrosive poisons such as sulphuric, nitric, hydrochloric and carbolic acid, lysol, sodium hydroxide, that is, lye, were common in Professor Milovanović's time. 2 Alkali poisoning is considerably more dangerous than acid poisoning, since tissue liquefaction prevents the development of corrosion scabs – a form of liquefactive necrosis 3 with marked softening and desquamation of the mucous membranes. 4 Lye can produce transmural necrosis of the oesophagus after only 1 second of contact, 3 penetrate to deeper tissue layers, 3 and by corrosive action may extend through the stomach wall and affect neighbouring viscera. 4 If the amount of ingested corrosive agent was small the injured person could recover, requiring later surgical intervention or suffering sequelae that may accompany them for the rest of their life. 5 The most common complication is narrowing of the oesophagus secondary to the development of a scar.
There may be spillage of the corrosive fluid on the exterior of the body, corroding the skin in a pattern which may be helpful in reconstructing the posture of the victim at the time of drinking the substance. The lips may be burnt, and trickle and splash marks may run from the mouth down the chin, neck and chest. 6 But in this case, the pattern of facial skin scars was not characteristic, and therefore was unhelpful. On the other hand, permanent damage due to the corrosive agent was only present in the oesophagus. This could indirectly indicate that the ingested lye was small in amount, and that ingestion was probably accidental. Professor Milovanović meticulously collected data of interest regarding the manner of death in all his forensic autopsy cases, in different notebooks, and this specific case can be identified in the notebook labelled as Accidents. Also, he used the terms such as “malnourishment” and “undernourishment” in the autopsy protocol and in the conclusion about the cause of death. Although only the height of the child was mentioned in the protocol, and not all the other objective criteria (head circumference, chest circumference, abdominal circumference, body weight, etc.) concerning all the circumstances, we can assume that the use of these terms was not exaggerated.
Today, poisoning is an uncommon type of injury in children, 7 but in Professor Milovanović's time one-third of all cases of fatal corrosive poisonings was accidental, and most were among children.2,8 At that time, lye was eaily accessible: it was a cheap substance for cleaning homes in towns, and was used for soap making in the countryside – animal fat was treated with lye, which releases fatty acid salts, that is, “hard soap”. In his forensic textbook, Professor Milovanović stated that that such accidents were often because of “unsatisfactory parental supervision… and neglect.” Also, “homicidal corrosive poisoning in very young children… is possible… There were such cases… occurred in very suspicious circumstances, but it was not possible to demonstrate undoubted criminal intention…”. 8
Today there are two general categories of neglect: deprivation-of-needs neglect, or the caregiver's inability to provide for the child's basic needs (e.g. food, water, shelter, medical care, clothing, and education), and supervisory neglect, or a failure of a caretaker to provide adequate supervision and safety for the child's developmental age. 9 But also, in fatal neglect cases it is imperative that complete medical and family histories be evaluated. 10
In 1879, the Society for the Promotion and Education of Orphans and Abandoned Children was founded in Belgrade. In 1933, in the Kingdom of Yugoslavia, this organization was transformed into the Yugoslav Save the Children Union, initiated by the International Union founded by the League of Nations. The honourable president of the Yugoslav Union was Queen Marija Karadjordjević. 11 But these organizations were taking care of orphans and abandoned poor children, and not the neglected, mistreated and abused. At that time, child maltreatment and neglect were not recognized and treated as they are today. The current Criminal Code of Republic of Serbia 12 recognizes child neglect, according to the United Nations Convention on the Rights of the Child adopted in 1989 and recommendation by International Society for Prevention of Child Abuse and Neglect, but with “reasonable considering of available resources within the family”.
At the time of Professor Milovanović society was extremely patriarchal, male dominant, conservative, poor and ignorant. Female children were a burden for families, especially in rural areas. This pitiable young girl with health problems and a scar on her face was undesirable, and therefore practically abandoned in hospital by her parents.
Postscriptum
The last chapter about this abandoned little girl is available in the Institute's record-keeping journal for the year 1928. Professor Milovanović waited for five days for her parents to take the body. Nobody appeared. Finally, the little girl was buried by the municipal authorities. What the eye doesn't see, the heart doesn't grieve over.
Footnotes
Funding
This work was supported by Ministry of Science of Republic of Serbia, Grant No. 45005.
Conflict of interest
None declared.