A novel insight into child abuse

Oliver Twist is a 'textbook of child abuse' according to a consultant paediatrician. But this is not the first time Charles Dickens has been cited as a precocious observer of medical phenomena

As a self-confessed fan of light fiction, it came as a shock to Patricia Brennan, a paediatric consultant at Sheffield children's hospital, to find herself reading, and enjoying Oliver Twist, Charles Dickens's dark Victorian-era novel of grinding poverty, villainy and murder.

As a doctor involved in child protection services, she was also stunned by Dickens' precociously accurate descriptions of what to many Victorians may have been the routine, unremarkable harshness of a life in poverty but to her was the relatively modern concept of child abuse.

"I was conscious that this was a 19th century novel but at the same time, there in the background, were all sorts of observations of abuse some of which have only been brought to the fore in recent research. You look at this book and it's all there," said Dr Brennan.

She found institutional abuse - Oliver's infamous stay in the workhouse, neglect and emotional abuse. Oliver is variously flogged: "The fist had too often been impressed on his body not to be deeply impressed upon his recollection"; locked in a small dark room, and starved of affection.

Up to the age of nine he lives in a "wretched home where one kind word or look had never lighted the gloom of his infant years". In the workhouse he is barely fed or clothed, making him "a pale thin child, somewhat diminutive in stature and decidedly small in circumference".

In her short essay on the novel in the journal Archives of Disease in Childhood, entitled Oliver Twist, Textbook of Child Abuse, Dr Brennan writes: "The sequelae of abuse, including absconding, passivity, stupidity, depression, poor self-image and a vulnerability to corruption by anyone who seems to show...love or attention, are well illustrated."

Even more remarkable, she says, is Dickens' identification of parental "at risk" factors, which again have only recently been classified as child abuse. Alcoholism, domestic violence, mental health problems and even violence against animals are all present.

The murderous criminal Bill Sykes is, suggests Dr Brennan, a classic archetype of the abusive adult: "While not obviously mentally ill, [he] is of a violent and paranoid personality, who also abuses his dog."

Dr Brennan is clearly amazed at Dickens' perceptiveness: "Abuse and neglect were recognised...in the 1960s and 1970s. However, it has obviously been an issue for centuries and Dickens certainly described all the categories of abuse..."; but Dickens is also revered in the medical field for his astonishing ability to describe medical phenomena that were not "discovered" until much later.

When the first medical classification of what would later become known as sleep apnea was made in 1956, it was termed the Pickwick syndrome, in homage to Dickens' own descriptions of sleep disorder suffered by Joe, the "wonderfully fat boy" of the Pickwick Papers. "It was not until about 140 years after the Pickwick Papers was published that we understood what he was describing," enthuses one medical essaysist.

A quick search of medical journals on the internet reveals 43 articles about Charles Dickens. His observations of deafness, physical disability, sleep apnea, epilepsy, restless legs syndrome, spasmodic dysphonia, generalised dystonia, alcoholism, psychoanalysis and repressed memory are all thought worthy of learned comment.

Barnet hospital in north London has hosted an annual Oliver Twist lecture for the past 29 years, at which distinguished doctors have used the novel as a starting point to explore aspects of everything from the causes of short stature in children and liquid on the lungs to muscular dystrophy and the causes of speech delay.

Two years ago the Lancet medical journal published a piece by an American paediatrician. It proposed that "when teaching our students about the medical ramifications of poverty and the importance of child advocacy, we could do no better that to point them in the direction of Charles Dickens... rarely have children had a more effective proponent."

But do Dickens' novels have anything substantial to offer doctors and social workers? Does his work offer fresh insight or is his perceptiveness just a strange and diverting footnote in the history of medicine?

"Medics can learn a lot from novels and poetry," said Dr Harvey Marcovitch, a spokesman for the Royal College of Paediatrics and Child Health. "I think I learned more about feelings and the behaviour of children with cerebral palsy by reading Damburst of Dreams by Christopher Nolan who suffered from the condition. Paediatricians, especially, learn a lot from novels."

John Skelton, a senior lecturer at the department of primary care and general practice at the University of Birmingham, runs a short course on literature for medical students. He says literature does add a new dimension to medical understanding but rarely in a strictly practical sense. Thomas Mann's novel The White Mountain is set in a turn of the century sanatorium, yet "it is not about the experience of having tuberculosis".

But at the same time it can offer different ways of understanding. Mr Skelton said: "Dickens has this piercing ability to describe things graphically. The death of Paul Dombey in Dombey and Son is an extraordinary insight into what you might presume a young child feels when he's dying. There are caveats - this passage is filterered through Dickens strong religious sense and his own sentimentality."

"But it does offer students a different way into looking at the world. Medical school involves a large amount of rote learning of knowledge. Literature works in an entirely different way," he added.

Dr Brennan believes Oliver Twist may be similarly instructive. "With child abuse people are divided. They either see it under every stone or they do not think it happens at all. Oliver Twist may help people face up to child abuse, or keep their minds open to it."