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The marks on Jessica – could it be child abuse?

A doctor's dilemma

“These marks look like burns,” I say to Jessica’s mom, looking into her eyes.
  • “These marks look like burns,” I say to Jessica’s mom, looking into her eyes.
  • Image by Joe Klein

The baby was playful; nine months is a playful age. Redheaded too, with that very fair skin that red-haired people often have and those chubby thighs and feet that babies have before they start walking. At this age, a baby without adults is a dead baby. The evolutionary message is very forceful, effective for seducing distracted, fretful, even warlike adults to do the right thing: look into my eyes, pick me up, carry me with you, keep me warm, don’t let them hurt me. A baby is all future. Who wouldn’t love a little baby?

The triage note was brief: “Mom concerned about abuse.”

Because I work in an emergency room, the babies I see are often sick and scared. A sick baby also puts out very clear messages: cries, gasps, wails, whimpers, and moans, or just the rapid shallow whispering sound of air moving through the nose of a baby too sick to do more than breathe and stare. Babies that are blue and still, babies that are red and dry and frantic, babies with eyes sunken and bellies like bread dough. Sick babies make grownups feel sad, a little guilty. And some grownups get angry.

Babies respond to grownups, as we respond to them. At three months, they look about for a while, as the situation sinks in, and then a lip curls, a forehead puckers together, creases gather and slant under eyes squeezed shut, and the baby is crying as if its little heart were broken. At six months, they are vigilant, provocative, look quick, and then turn back to hide face in Mom’s sweatshirt, playing peekaboo. But they cry quick and loud if you move too fast. And at nine months they are bold and exploratory, reaching sometimes for a mouth, for a nose, then flopping back to nuzzle in Mom’s neck. At 12 months, they become inviolate, untouchable. A year-old kid will pick my probing fingers off his body like a bug. It seems to take about 12 months to grow enough brain interneurons to connect the idea of self. Some cultures wait that long to give a child a name. At nine months, this baby won’t completely know who she is. I let her stay in Mom’s lap and sit down in front of them.

The baby immediately reached for the tube of my stethoscope as I sat down.

“Hi, I’m Dr. S. What’s her name?”

Her name was Jessica. Chubby arms and thighs, the skin electric with the immense energy of growth. No obvious illness, no dehydration or apparent pain here. Chewing on the stethoscope tube. “What’s wrong?” I asked.

“I dunno,” said Jessica’s mom. “She was at her father’s house yesterday, and he brought her home late, y’know, in blue jeans and tights, see, and she was tired and it was late, so I just put her to bed, without changing or anything, y’know. And this morning she got under the bed and kind of scratched herself here, see. And then I wanted to give her a bath, so I got her undressed and cleaned up, and then I found all these kind of red marks on her that weren’t there before. See?”

Yes, red marks. On the arm and the leg, on the chest. Let’s see, here are some on the other leg — both legs — and look, there are two on her backside and on her thighs. Jessica squirms mildly as we turn her over off Mom’s lap, our heads bent over her body, talking about the red marks in a kind of academic forensic way, politely avoiding any feeling. Partly, my brain is trying to diagnose what caused the marks. Infection? No, not all over. Maybe fungus.... No, wrong distribution. Impetigo? No, no oozing or crusting. Some kind of virus or maybe burns? They do look like burns, but what would burn like that? Another part of my brain is blowing a whistle and pointing and jumping up and down, screaming child abuse. If these marks are burns, how could they possibly be accidental?

Now Jessica is right-side up again and reaches out and snags my nose, latching onto one nostril for a moment, baby fingernail sliding off its grip with only a slight scratch. Nine-month-olds are hair pullers, nose twisters, and earring snatchers — not from malice, but because of curiosity and not knowing about letting go.

“These marks look like burns,” I say to Jessica’s mom, looking into her eyes.

“Yes,” she says, “I was worried, y’know, so I brought her in. They weren’t there the other day. And her father has a new girlfriend. So I’m worried.”

“Do you think someone burned her?”

“I don’t know, but look at these marks.” She points at the thighs, where the whiteness of the soft skin on the inner surface is broken by the curiously precise red marks. There are two on the right thigh and one on the left. Each mark is complex, a hairpin loop ending near two parallel marks that look darker. The borders are crisp and clear, exactly like a cattle brand.

“What about this?” I ask, pointing to a bruise on Jessica’s left shoulder. Faint, still slightly purple but mostly yellow and green, it’s an outline about six centimeters across, two convex arcs connected, almost like the outline of a lemon. Nothing like the precise red marks. “I wonder what this is from,” I say.

“Oh,” Jessica’s mom responds, “that’s from her older sister, my four-year-old. She bites.”

Suddenly the imprint comes clearly into focus, revealing the action. A mouth opening, the teeth protruding, a jaw closing, the breaking of tissue, the sudden yelp of pain. Of course, a bite. And four-year-olds do bite. But is the curve of the jaw six centimeters across at four years? “I guess this is from some time ago,” I say. Almost without knowing it I’m beginning to excavate. Jessica’s mom says she’s worried about the father’s girlfriend abusing her child, and the marks sure do look like burns. But what about this bite, and that mark on the tummy? I am up against an event that is not exactly what it seems to be. I can sense that I need to move gently, but I’m not sure why yet. Abuse is possible. But I remember other times, when I jumped to a conclusion and was wrong.

Once I treated a 16-month-old with burns on her groin, her leg, her hands, even one on her cheek. The dad seemed puzzled as he told me about finding the kid crying and burned in the bedroom. I didn’t believe his story; I couldn’t imagine how the burns had happened without someone intentionally doing it. Dad was outraged when I told him I was going to notify Child Protective Service. Later, a worker told me the kid had probably pulled her mom’s curling iron off the vanity and juggled it in her lap.

And I talked to a young couple I felt had a textbook case of relationship problems. They had brought their 13-month-old in because he was “sick,” but aside from some bruises, I could find nothing really wrong. I talked to them about not using the kid as a focus for their own struggles. We had a long talk, they cried, and I had a good feeling at the end. Sent the kid home with them. Next morning, the doctor coming on shift passed me in the hall and said, “Remember that kid you sent home, the one with the bruises? Well, he came back in this morning with a broken leg. Looks like his parents slammed the car door on him.”

Jessica is chewing on my stethoscope, and I am looking from her legs with the precise red marks to her fat tummy, where I can see a large scratch that has the surrounding reddish flare that persists for a few hours after an injury. This seems pretty fresh; I invite Jessica’s mom to look at it.

“Yeah, she got that crawling under the bed this morning. I guess she got stuck in a mattress spring or something. She’s always crawling around where she shouldn’t. She doesn't mind well.”

Minding well is, of course, impossible for a nine-month-old human. Mind is a property of interneurons, and Jessica is just now growing these. Newly independent crawlers and creepers, nine-month kids will eat everything, crawl everywhere, and learn by very basic trial and error. They are strong doers and rudimentary thinkers. How does a crawling baby scratch its belly on a bedspring?

“How do you mean, ‘she doesn’t mind well’?” I ask.

“Oh, she makes me really mad sometimes, y’know. She just always does what she wants to do. I mean, she doesn’t act like she hears what I say, sometimes.”

“So, what do you do when she doesn’t mind?”

“Oh, sometimes I have to teach her,” says Jessica’s mom.

“How do you teach her?”

“Oh, sometimes I spank her, just like my dad used to do for me. ‘Spank them or spoil them,’ he said. But mostly I just tell her if she don’t do it, I’m gonna teach her to mind.”

Teaching is an important part of parenting. And teaching can take many forms, some close to abuse. My father once reminded me about a painful learning experience from when 1 was about three. We were in the basement and he was using a big old soldering iron, melting dull solder into beautiful shiny gems as he fastened metal strips together. The iron looked and smelled exciting. My father told me that if I touched it, it would burn me and it would hurt. He did not make me leave or threaten to punish me if I touched the iron. So I touched it. And got burned. Abuse? What about spanking? Probably my father spanked me four times in my life. What about Jessica? Maybe she won’t mind; she can’t mind. If her mom or someone else has decided she has to mind, would she burn her to make her do it? To teach her?

As Jessica munches on the stethoscope and rolls around, I look again at the marks on her body. The bruise on the shoulder and the scratch on her abdomen are different from the other marks, because all the others have the precise bordered red color of partial-thickness burns about two days old. That means that whatever produced the burn was hot enough to kill the outer layer of skin cells, but not the inner layer. Jessica will grow new skin under the burns; there will probably be no scars. A partial-thickness burn is very painful for 4 to 12 hours afterwards; burns made by hot water or by hot metal objects are often partial-thickness. I can’t imagine how hot water could make these precise marks with so many different shapes. But now that I am looking again, Jessica’s burns are not really all so different. “Look,” I say, “do you think these are different than those others?” I point to two parallel marks imprinted into her left arm near the wrist and then point back to the thigh. “And look here. This is more like part of a circle”; I point to a semicircular mark on her right calf.

“Yeah,” says Jessica’s mom. “Couldn’t they all be made by the same thing?”

Jessica has lost interest in the stethoscope and is squirming again. She shows no signs of pain; she’s perfectly comfortable with her mom. “Yes, I guess they all could be from the same thing,” I say. “You mean, like, these little parallel lines here without the circular thing are the same as these heavier parallel lines with the circular thing? And this semicircle is part of the circular thing?”

“Yeah, I just thought it might be the same thing,” says Jessica’s mom.

I wonder if she knows. “What do you think did it?”

Jessica rolls over, making spluttering noises. “It looks like the top of a Bic lighter to me,” says her mom.

I hadn’t thought of that. “You mean, one of those plastic lighters? Do you have one?” “Oh, no! But my husband’s girlfriend, she uses those lighters.”

“You really think that someone would just burn her like that? Why would they do that?” I really am shocked, perhaps outraged. And so I ask why, something I would ordinarily never do. “Why” implies surprise and negativity, a search for motives and causes. Generally, I ask how, which people understand to mean in what way or manner — a far more neutral question.

“I don’t know why. How would I know why?” says Jessica's mom. “Stop that,” she says and lightly whacks Jessica’s hand away from her earring. “Anyway, his girlfriend, I heard she had her own baby put in a home.” Jessica’s mom could be right; abuse often arises in families that are in upheaval. I think abuse comes from confused feelings of love and the need to be loved, as well as a demand for control. After all, an important part of love is response; a caress becomes a part of making love if it is shared. Suppose Jessica did not react enough to her father’s girlfriend? Suppose the girlfriend wanted Jessica to embrace her; suppose she told her to “come kiss Mommy.” Suppose Jessica didn’t. Suppose the girlfriend really missed her own baby and put herself into a contest she couldn’t win? Suppose she said, “Jessica, if you don’t come kiss Mommy, Mommy will have to teach you a lesson.”

“Maybe you’re right,” I say. “Wait, I’ll see if anyone has one of those lighters.” I get up, walk out of the room and across the corridor to the nurses’ desk. No one smokes, but they call to another station and tell me one is on the way.

As I come back through the door, Jessica gives a shout of anger and pain. “I had to slap her,” says her mom. “She just won’t mind.”

“How do you mean?”

“Oh, you know how kids are. They just think about themselves, and sometimes you have to give them something that will make them realize how to behave.” She hugs Jessica. “Okay, you can stop now,” she says.

Suddenly I remember an incident in a supermarket, turning down an aisle, and passing a crying child, angry mom, half-full shopping basket. And then, unseen, a radio play of sounds: the slap as clear as a pistol shot, the sudden yelp of the child, the mother’s defiant voice, “Now you have something to cry about.” And then the kid’s wail, gradually lost in the noises of shopping. Would burning with a lighter be so different from slapping? Suppose Jessica cried. Burning would give her something to cry about.

“Do you really think that someone burned her with a lighter?” I ask. Jessica has stopped crying and is turning her head to look back at me from where she has her face buried in her mom’s neck.

“I don’t know. All I know is that my husband, he used to beat me up pretty bad, and she came back from there with all those marks, and I know she was with Meryl, that’s his girlfriend. And she smokes, and she uses one of those lighters.”

A nurse opens the door, brisk and professional, holding a disposable lighter with a bright plastic case. There is a little flick wheel at the top, and I flick it but nothing happens. “Here,” says Jessica’s mom, “let me show you.” She takes the lighter, depresses a little lever, then flicks the wheel. Jessica is suddenly very quiet, and I get a quick glimpse of her face, the eyes fixed on the lighter, the brows furrowed, the lips tight. The flame kindles. It stops when Jessica’s mom releases the lever and hands the lighter back to me. Now I have the lighter. Now Jessica has returned to squirming.

I light the lighter and for a minute try to get the top hot enough to burn a mark on a paper towel. I think Jessica’s mom is right. The flick wheel has two ridges, and around the wick of the lighter is a curved metal rim. It looks to me like they might make all the kinds of burn marks on Jessica’s skin. “Maybe it wasn’t exactly that kind of lighter,” says Jessica’s mom.

“What kind was it?” I asked.

“Well, like that, but the kind I think his girlfriend has, it’s, like, a little different. Why don’t you make an impression with an ink stamp pad?”

I get the pad and ink the top of the lighter. It makes a clear red impression on the paper towel that closely matches the marks on Jessica’s skin. Angled one way, the flick wheel produces two short parallel marks; angled the other way, only the curved rim appears. A lighter like this, if the metal was hot enough, could have made all of Jessica’s burns.

“How did you think to use this stamp pad?” I ask.

“My father is an investigator. He investigated stuff like this and told me about it.”

“Well,” I say, “there are certainly marks on this child’s body that look like burns, and it’s certainly possible that the burns were made by a lighter. I can’t imagine how she could burn herself, can you?”

“No,” says Jessica’s mom.

“But then there’s the bite mark, and the scratch...”

“Oh, those are different. I told you where she got those.”

“Oh, yeah,” I say. “But didn’t you tell me about the burns too?”

“Wait a minute,” says Jessica’s mom. “Are you saying you think I did that to her?” Despite half expecting some reaction, I am taken aback by the level of her abrupt tone of dislike. How do humans do this? Is it the sudden direct gaze of her eyes after minutes of casual contact? Or the sudden tightening of face and neck muscles? Jessica herself is silent and tense. Maybe it’s in the breathing pattern, or maybe I perceive a change in smell?

“No,” I say, “I’m not saying anything about who did it. That is not my job. What I do is make a report to the Child Protective Services. And they will come and talk to you.”

“Talk to me?” says Jessica’s mom. “What about Meryl? What about my ex-husband? What about them?”

“That’s right,” I say. “CPS will talk to everyone to try to find out who burned Jessica.”

“But I told you,” says Jessica’s mom.

“That’s right,” I say. “You did.”

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