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Artigo de Caffey (1972) SOBRE SBS

Artigo de Caffey (1972) SOBRE SBS

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  • 1. "Pr rtN4 - Atiguat.19721; , • Vol 124 N o 2 Abrah . .„ • e Its Potential Residual ,•E ,.„..,•• •••,,„, •• of 0 . t r # 0 4 p i i t t 9 • ••, ••••••• • • , ,•1 , l . •S i * i t i : • D O . J B e . 0 •l i i t e , 4 - • r n a g e : • c 0s :t : : in 1946 of the paient infant : : ; • M O k i stress öf r y n t i rb * e t • „nct c 4 genie vaalcil;umenaornZhogpentiv:sehlkpilgh?; e s f • syneir:§00;,*4esci7ihecl t 0 , 1 : ; • : : I t e . i r :n e • • oftenh d i s t „r ti b u t i :monthsS ), younger, whtods u t f : 9 s yx o r :t(P th e combination4o f subdural i R a fi g • tiom a n t s , p Ibone lesions i h ie n rf o matomas and characteristic bone ; hi • o n ITS m u s t h 1 e d 3, • r b a t During the last 25(..years lcsLons t : : C p b e i n _ e e a r t g a n t : l i a k e y i d e ri e ; , s t e d i t ; b circumstantial, has gradual* a6;: :sad a t a f cumuIateCivhick:: suggests: tb4,.:::the b o t by " , M § b i ; u iibused infants are common . whli4lObiabaking.:•,::: and je rkin g . i t boneg : k o rc a taisr0100.10,4):•;*.01; aa.;.theeerehro: l ue s te t the o f , t s : , • : vascatArte0Oti§; • t se r 1 o 1 4 4 0 ; c i t 4 e • s • n , the mo s t c ommon cause o f t , ,tle I u 011: iPlic at ic k pl r ma n d a t t e riS ! , t , g9#0;YAWeinvite your agOnt,ion,!,tn.• h e evidence which supports our con- the . o toh a ts: ; , : : : t h : L• m s cept , d a r jerkmg o f t i n t s a re frequently E t lash-shaking is practiced, commonly in, e , f pathogenic and : t v h i O a s h 4 o fh e t l t a Wide variety of Weis; Under a wide iI qf e : a a permanent d a ma g e t o i n f a n t i l e . variety of circumstances, by a nea- kIng,a n variety of persons, for a ytride,jrai:iey„, m t lia t : iii. o p iit ia lly, :b d out , of ireasons: os c4 1 :r : , w de,, m d sn it i n , a fOi, h e : T repeated WhiPlaahahakinge,f, fragments 0 re : : fants and young children is to correct :d irea ,i - iig 3eceivedi$ g:publication,Apr il 12 1972 1 : a 0 o q ii, cfor mn o s n ,r a : , Minor miabeh av ion Such sh ikings are • a c nand p i i * t h e departments of radiology :and pel t tt m .t r taes pemae;,to,irrtchkip i ffee- h e s s , ac diatiiii;:School of Medicine, University of Pitts- generally c oparents : and physicians. :If , s h et e r ,u1- 41 a . both ; r, o c a ! bilitli,"faiid the Childrens Hospital of Pittsburgh, c r .,.• ; Pittsburgh n m o u r / of th e pathogenie, signifi- r r i sa t t t concept ,,o m s c n c 1h:,:tniesla.no pus n gr1I _ : tadt 2 sl haS i t r t c pacnh s - 6ee e i h :Oa e d Read as the Tenth Annual Abraham Jaeabl, o n of whiplash-shaking, is valid, it cance e e ue # i i i i k Aiiy)**FlOaaaif before.:: the 121st annual :con e follows a l r tio e tor nosal m,com i d e r that the prevention o f such r0 , o u tnhonrIt,reoseedr s m , tsheass s ale7wttbsu le / f ods e b n ce ta 1n e n , h:e a e l e n o s t v m o sReprint requests to chi l dr en ; H ospi S a. ) t i anc i § shaking and jerking might substan- o t:IdW e d a:anor o p weto t iInce r y t i 1 r vu v fia91) as1 l1om,,nslsio a n d oin rme n c . s :e. o t t i o : : n n ala s itially reduce the incidence o f brain e ln6onihqnv V . . Traumatica o Pittsburgh 125 De Sete Si, Pittsburgh 15212: sO t ; : . , l ar i q cA r e vdamagee and mental retardatien. The , • P sav segment r fo o ( c u l only e c n v t minal n t nm t i e s T1 Y: 1 :1 - Cs4 fM e W : o c rvemr h e . tt 2 al 4 Psee:skeibs e l tr peo - .W 0 , ie a 7 u o p lv r etei y s e e n te:: t2 fhf s wit " 1i c9 t i 2 i e aoi al Amer Dip ,Philci/VoI,124,, Aug1972 u s Damage from WhiplaskShaking•of Iirifant0Caffey 1 6 1 a sareteari s h o .0 e M , 3 r c ti tching, e r r 312 4 d i c e tlioehrr h 9es : e . e Y n l a 1 b s d b e 66 e s rdo e xl 1 " - a A s 3 r h y ,r u f r y tsi: e T l s o , e u a p ofli
  • 2. F-U 11 - •••„••••• • • • ,, , • , : - , s u p e• i • spicuous o f all t i anmatic lesions in imposed on the haft, but after four growing bonesl l t y ea d most con- - U s u a h Tny are not lg te rs a y e ht fracture-dependent They develop due : W to traction-rupture of the abundant .. . . . : : : • • normal p e rf O ra t in g " : ; b lo o d ; .: The entrapped subperiosteal b1oo 0 which course througif.,thelettotieal•Valt t t;then::gradually resorbeci The n a 444 - -: : : v e s s e li, . •l e . . : and distribition of these lesions 440t.no c „ullary cavity and -ivIlicli•047.0.:,00„.iier•Oct...47:•;:,. : be best explained on the basis of i1 ( i- - 4 a n ?1 the junction • .0.10:„Inten.a:,..:•ecike",:of ., V h ii : a- "• . ti0k4r0t,f,0*d.;*gi*iithOperiostetlm e ••:,• • : , . (4 •• V -••• tof "04kO4 : . joint: ,,_•,•.••••• blood •internal• to• tne perieetetiM :: its vessels, and thefp, i a n„l e„4 t pg • : • • •• • • „ , , r On„n ag iz ilAilp it . 1 i - V ••••butextern41 i . whipla •_ .: 4 h e , ithe Periosteurn.off;:.the•••wall t h 0 , . extremities andh s h a 1 N ,h d a e , able: distances and I o - :h distribution can be , : - satisf , t er t h e i r ce teallImatp.mas•Of vanable sizes and # eih ed - o ernt , i* c a ii n a t on theebasis actoi i1y _et:; ••• :;••:, . ••• •• . : n •• ehappa„ m4 b plained u r of•,_ •its vrect s h n ) w o l b ( e r t :!,fOr.; • l • ••analogous. bones. _ •••••••tivoartriS a n Severaltobservers have noted - in •• ,•• " • • • : la. the ",• •••••••,:•••,• r • t o . • ; • legs;„ or they affeet, bones in the aims.• o c i art e d " , d i f f t i s e l S cO r - i la : O f t- •e n e :4 and forearms: • •••• ••„.„: : • : n some o f : : . . . t 1 metaphyseal fr ag- e Or::: •• • ••••••••• : • •• t h •,i the*e • ••• • •• s . Fre- UPrt a infants Th is has - : only , abused - P suggestod i 4 k•.xcessively fragile,:brittle, ,chalk-like .e - . O : - quently i rn y o l y e m ,: , Celaticationi (pzc) on the proximal ti de of , t, o s- _ . A T ec!Mp e .•r:.o thQkneei in the femur and the distal side of a the distal.. p r o x i m a l , sides o f . th e m e t i h i : bonesIto * e . i , U W. 1 1 s r the tibia of a patient 4, months;ii, • ,••_ -• „ ointl , _• ," . b 0 . • , • •_•,•- ) •:: . •:,l . geh . ,ohS y 0 i0 s fi St y nc , lappear radiographically :a 4 : , r rn t , l b e 1 : i o f . . . . .s: . :l 1 t i o n O S i § f . mination:disclosed, 1 1 2n , , • , ; )voven pat- r -: - . t , , , , • a M OsPi e a , • •r • . • , 0a d i o l o g S t t ho S h a ; t S O m 1 , , • , , • , , ee e ::• . . o n s : O e ,: i , i : , ha i. s t s 0e exces- b :• o :t phe :: • • • • • F ,i ; : • • • : , ar- : :•;•- •- " sive :n I ° .- , newly• r pf o :,. i , : ; f o r i n e d : r i n i t t; i . e o : : .c i .i : , V n• 0. e c . v_, : a l under the perlosteOrn" f5 a ,: : ks .1 4 n t e hp: .Fig::• b r o u s ly • l.rnur,& with . , O e . 5 A - : _ e. : _ curve:::,.;..:::::„: :: : : :.: ,„.::,;:.. ,.,;,: .:::• :::: .;:t,...„ : ,: : ; ,: .::.;,,..:: : .,. : „.„.;•,....:, :, ,:,...:•::::::":•; ! " „, _D•:• " . " • . • • „! ; , : , l. *. 1 1 thickeningsn - s(___;;;..,,;.:::::;:.; :., , d line (arri74/4/s :, opaque: ?...:. , , „ s , tom " 4 *i: , : in g ls of e ,l i . ,:,.,„-•, - iap • oe 0i ; - :i the external s u b p e riu S t -e rg:f r-A r n l ) .. O io „ ris n;t s l i ti y a fi n e . nn n i g i•4 •t , :: n e S y r u po r i m p o s e d or ,l , r o s:pi U . The epiphyseaLOSSift i s sm m e b o t l h . ea1 ,,,ii :tos n. _ n to t h o a yt c e -,- !s i •• , •—• ,, • T r u m a t i 444,611 :ie cs e n - : ,-• T h e sclerotic. shafts are -d e. t r w .e e „ i p O . l . ! - -•••-_1 s t0 ;:ro n g e r than nortriallSh44ts. ,#0 - ls i .c he t ;n m, e , ni k •::„ - • , , ) ap i p h y s li n - . , , :e TraumatictmetaphySeal:::!•.:eilpptut.,: is - •::: o f h ef• • , , „ ,,_ - „e . .io d : li ep ,.• • d us e to traumatic obstructive:;ipPrY,: to •e ms l ,fo i a , y. e .hthe epiphyseal : a ,. . d e. e f e : 1t -t d h . „, fdboring r i o l e s plate. . . . acr t e cartilage „. ,h g _ t, s - * - e e a: , r i ;• t •ei t n , "loop7,, d e . o r, Miie e ! taphyseal - f eto stretching , and••!ciio#onSiOn.,:;O ,g e 4 •p . :l :-fvtii aumatie i n v O l i i :• - . ; .: p, i i rh s , e o: . .l h o . . 1o h •a . r :,..: e.. fl..these .l e s i o n S- ofi:Ahe ,l io : r , e the t , : :n : r on.a#U cca u„sa l: : h a . ••• , , :,O •,,,,, : • ssi: •„ :, .v y , f " s ,l t . : :t ; C,• • m s; *•„4 u e t h o : , e ] t t re n squeezing 0 a •,•,: .:g r e : , l : h O S t l •i. si : h. : t a -a- h i sailants hands, and „whiplash-shaking : e n i ei f„:n e , t F i l - !,s ;- e, : : r :qei,.tinfants ; , M e - , the 1 , , : . 1 e . o,S : • i , Despite the fa 4 n t..0 . ,i, a. :o t : d o- t , t M ia:l4hrOn di i .tg l y , , ; t en ie, i 1: l . ,n i, h r u.physicians o tol,apprepia,t,tho,- hl : a d . . e :, tsignificande...; -a ". , , b 1 m o n. ol . t...,:;Pt4 t0 - • f- o ; B o :. younger infants, and •- a : :, , i u dh• • „h , l ? a e • ::::•,. .•. ,y : -, :• l: f i • • , - :,..,:,.• :, z n n :",:kS : , , l, _ • d -- e- n1 * .n d ! i:. : q g •••„•,,••••••••••,„••„ o -n p1 • ..,..,..,•:,„,:••••••••• • ,•• • ••• • • • • • , - ,-A • u 2 7 9 1 g d :: ..ing• t h:e ,: : : • ,,• Brain Damage. From Whiplash-Shaking of Infants/Caffc , l ; ,e i:::of ve : • 4 : • , • z , b :w :ia ,e :. .i.g , t -o e: . , c o - . i::::, :- (; ,as " - i f A: • . n l i,e : O g , :: Jih :: f : s f e - : j:: ! , • • • : :
  • 3. because she whined (2) A girl , 4 years, ofiper- ageW Shaken violently because Of inces- asfour e sant crying : .(3) A, girl 4, months Of ,age;was new some and,At,thp,„ same time, the most sig- shaken faUlly during Which , fRind iufi banged , h e ragainst, the crib h e a d , yetm a. whe ca iplaSh141 a wr s a s counted i n k t fi g A t n i b i f - 4 1 s)d is - na . t •ture - o 31(THREE CAs - 0r M0 , * nt fote l , * Y o y , : i l l O d 4 mont swiss explained cOnvulsioni, and h ts h, can ported a n t 0, liit l 4t fever • His mother Was • too shockedndi- maimed I t VtlieriAtiiiiii.a;;Iier,idrlof eight. , . h t k 0t h , t 7lO Og :O,V I 4 y years, V9sera- , a i n i ea r l,. : and t heir blood vessels 4antile brains I n 0 i ;: , and e ndied, ,three days later Eventuall a k he iA ,- , These assaults all occurred in the homes of;ules sh l n l p , fii f a a t s : I p•p e r - mi d d l i 4n 4 n S s i a t d y4 O , a 1 s thehm her•aclinitiecl thatshehad shak m i ot the u 1l parents, who provided expert medical: . a u several times t6 f r o p t b , •" c h o - d do , en to death" cltirine a violent PitroXYM of Og 5 WYd : : •- h i g h . i k „ ; . - t 4 4 1 n1 n n ? iing rcoughing StiP ,ha t t e mp t e d " c l e a r his 61,I a the caree n . )y (4;heir f services 1 4 . i .; throat: and he went into convulsions l b ex- 7 demand n o, jp e d i b t . 0 0 0 S , . :lowing the Shaking. ( 2) , A boy, 6 m onths ns : . : edt , 00; t ed. V e . 5 for bein tion e0 4 began to vomit and cnnVulSe., There old,pact f c , Sarc t 6 . ; P awere no external signs of head injury but infant . u s charges Both parents d o c t o r s g a 0t l n g , p: ia e r . : : : t n :0 u , • - ;hemorrhages were seen in both ) tretinal appareiltlY:Jliakitilegnfidence in her in one . " ee x t r a r , lodder fundi. Subdural hematornas were insto.4e4d..Wkin),i,ited back by the par- . b au v g e ents , i opa7i C t s ee c o n d infant h : atreated surgically:, (3) -Qifle i t i lhad shaken their first child to death_ ; Ate :f jt e r g n 4 . , patients twin brother came to the hos- this , v a , n O tA 1 e w andunexplained broken femur. fragmentst ; both ends •of pz0 tAf t ,tef , ?inf ant W found dead without . n l tpital1 Fig 3.L.,11nexplamod a e . as o r with , f a y-like u y aVdt adt pry oShortly thereafter, the first twin returned, - s d t ipn M m1 ; persistent subdural hematomal By •with , : y• s tures) of the left femur with fine thin2ent p l444 P - t( rn p m a t i c auO p n i d a t e r , nal thickenings of its cortex which 1:0Iiee_sent ex- ,: p abubble up " I 0004 him tin and tried to , a time bruises had appeared,on both elthis , r a c f f r a c t u r n t o!, 5. ))14,; p,: .,441: ).do-anything aI nhe.1 0 , e forearms, which fitted the pads in the • o0 lget e k o :o :T: 4 whis e tAe a c P i a t i a to o * p r ,..p f twxongyy,Ne i : i o a fingers and thumbs, cif: the , examiners the distal t h e two ,i;:,Shafts;-pat- - e o n ;4 tsuccumbed unexpectedly, she admitted o fbands, where the boys forearms had t s theselesienS;indieafe•:that the infantatesb, h: a:ces, h s S he O . s ( o h . that . t egripped by his assailant during t h Eventually, the mother admitted that l r,ponths) had been splidd by hoth, ,erous e e r P a ti e n ts h e h liecropsisliselcided.,tranmatiebrain injury. : g i e u t i tra l i y : : h n ing, s h a k he x and her husband "might have shaken B a h n w she d r nt seand maiming two others. When these -04 e! : s f • c ihim when he cried, at night " Guthkelch rvent his t d :raü d .1 n a d M xt t e d e admissions became t o the commu- o i iopines that ,a.• "good shaking" is f elt by Si*..:WOqns;latOi;:;itiftftsIv:iItiVOluera?,!Oine l; : tBritish parents to be more socially accept: r adius and Oink iff.the: SOlidlifOiO4fn. were ed- o i. l , in a d , g in disclosed that ten additional nitYPEirenta - s y h m , ,n fl t r a t e d : : t e o4 k ll l: had been significantly injured by n n i infants g h able, and physically lefts dangerous, than de o s c , eh : r e v thin nurse t e 7 rO 3, ; . , O of r weeks wass ai dY, y h i m a blows or punches to the head. : , : to have suddenly de44V e Tile primar d ExAmhz 4 (ONE C A s E ) . tf a d il o gar S r : t * a veloped unexplained swelling, t r r a, : described radiographic bone lesions caused eu t k i Iy o p n i - iS 1 .inaA ttii .g j! * g k : hours latei i. 4) 4diatr i- 4 fi . d l and fever. ,Twelve ln e e O l # 4 h4Y.:heOn:,yiolent::. whiplash shaking and byK e m p e the repeatedeparental shaking of a pre- . f o r e t ieian diagnosed g s t e o r n S r e l i t i s : g o eiC8diaiit.e:Whiplash;•Pennding on the back maturely born twin girl of 7 months; who because o f p o i n t : ly r §c e d a l had been abused by the mother since the -and ; 0 . 0 § 0 4 a during burping One is amazed that she o d : , O tslight fever a n d : i 9 second month of life. She was shaken while ,a . .,re n d e i t , s h a ,, t k 0n satt4l*thiS Much.better-than7aVerage so- o ; k i n gripped by the legs and held inverted. Mul- y l e begun. e y t o S i showecUOUld,On rwas : . nkO Radiographs ciat,and a a t medical milieu for eight years. I t tiple massive involucra and several me- fracture fragments at,::th0:;.1.PlYPt,,* one g t i , g likely that she did not realize the full .a e l ,sh: 0 :i *e§ ; ! n Srei s (g45i is lc a taphyseal avulsions developed In her fe- tproximal tibial metapnysis w n t q l e „ — murs and tibias. n * e l: Later films showed ; the evolution * trauma pOW4r. and violence generated in her shak- k ls : i- t an k X EXAM 5 (ONE C A s E ) PLE o a longf:;tratiMati,inYnitiOtn*.Offiis of4.0 i oo u i n d wha tn .d : d ie k iC ethe t ;(2,33Ab), and was said to have had very d scribed compression fractures of vertebral b ,-- tibia, e , th nf lart,Onands,,Il.be last infant she shook to h bodies iin c h uinfant, which were believed rthe 19.tki day;,.. Sw s one k m . . s ma idOft,thi:WOignftd:.:497 k g (11 lb). Had the e n !l l to be due to whiplash-shaking. l u .i. . prior to the.aPPearandS.Of the SWAing mjust , . frnOkneetishanOnhy a caretaker of corre- EXAMPLE 6 ( T H R E E CA S E S ) . —W e h a v e : d examples of protective jerking e - a the n o she had E of knee, s, h leg and jerked;her M t t •e h h o t t ; t • n f iSOncling, W ght.,.1. and :•strength, the mon- ei found two the a g a a a n would haye weighed 21 times her ster and one of repeated sibling whiplash-shak- e e hfrom falling y g a hard wood floor t ye r , r a n onto f O e A! Wa s; her - h n ing. We have encountered two patients in , t; ) W ab t s f fi d i sthe:same time she had, fallen,forwatd*ith tweight or 2 , 2 2 6 kg. (5,000 113) bs . y •t I, s u n ; , t. a n d whom a single, sudden, violent jerk of one .ther and onto her ThdPedietricianWtaitill iWOnIct;hayOlhaid,the s . . ,g . : t Oa women srengt h. t : extremity apparently produced metaphy- T in . S 1 # 4 0 C t ,#.0 aAT,44py,,2:(Fpn*CAsEs):.:LWeston seal avulsions and traumatic involucra. (1) rO c h r i a d t r a u nn d . • b e e a u d e of rwith the frequency of feYeranctileuko- h f and Pollock. report: low cases of o 2 1 A boy, 41/2 months old, had always been Steele d p6 : a tn r o n g a t e c y e t .täJ ,s epathOgenie:Shaking,in battered babies (1) well until his mother grabbed him by one e : h O , after traumatic,. ,iiitdrnal!,:[....;:lieinor- cytosis p , : forearm and yanked him upward to pre- a l, y : rhage.t. (3): This boy of 8 months had hadar e iiilgirl2W,::Yeara old, was shaken violently • w , • u 4 • •t• , • ; • • • ,••••• • " e ••••• • "• • •• tT t : e a Me l Wa S t t f t f 4 i n i l i a r c , t i Pis Child/Vol 1 2 4 , Brain Damage From Whiplash-Shaking of Infaidts/Caffey 1fey r et i o g , s na t ; h Aug 1 9 7 2 , t n t: : e o t O * i c d t tf o 1
  • 4. - e , - Fr i l a i n e d Massive tr aum ati aVulaidnat;tty,e proxi : mai and c ! o itiyoltiOra months of a , of 6 , boy 12 month$ (Alt Thedistallhied of t h :00tiO::gbbse T he external edges of the new gh t e e e - fi l is 0 O h ,o s w e f old, and thickeneda u r n a t i C c : : shaft fused t r atids•pler f l e n d s 4,ncti,ffilall blackish patches which indicate ie t t ,parents, denied, physical injury • , (.056YOn resorption of blood or repeated trau- t o f imatio.opisodes with recurrent subperiosteal 6 p u r , a , e Iat . i t o nv a n h t h a,teedisg bl, t ,e n: n 9 m e sd ue d l u Cj i i n . T h e r hn i b a r s Fig , ee d traumatic involucra on the anterolaterat as- - n e r o lt r pects o f t he l ef t hum er us o f a boy 1,3 a l h f ,. la months of age whose parents denied trau- a u , a f t matic abuse. This arm had been wrapped in a- n — a bandage which bound hi m i n r estr ai nt r i duringe performance of a cerebral angip- U n the e gram, leight weeks earlier. n xp u f ai n n a unexplained swellings and tenderness and heeseized the infant l t h e legs and shook d These 2 7 examples o f recorded e limitation of motion in both legs for s e- n him violently, and swung him, and flung l pathogenic s hak ing represents only v him onto a bed. ,t rai Weeks when radiographs of the skele- a an infi nit es imal port ion o f the un- e EXAM 7 (Two CAsEs).—These cases in- PLE ten, disclosed- traumatic involucra at the 1 r counted thousands of moderate uriaci- , n ,proximal ends of both femurs. The parents volve oculovascular lesions. Gilicesl g 3 mit t ed undetected arejected the diagnosis of trauma because, tions e case 2 em the n - of Wallis in which subclural whiplash-shakings which, probably , a n d nother • than themselves, no one had been hematorna and retinal hemorrhages re- c sulted from seizing an infant by the legs cur every e c o t he Unit ed States. u n r day, in d4,:o4 with the infant except his 8-year-old e tbrother. He, however, had frequently acted , and swinging him in a circle about the par- The actual , dailyincidenCe,pfjpitho- r d e d n ents head. He also refers to Breinins in- genic shakings in the United States is ;aka lone bahysitter when the parents went h t unknown, but it is undoUlatedlyAUb- e socially.They found, at the first trial, Qut fant patient who developed retinal lesions secretly watching r after a parent had gripped him by the tho- stantial. Th e , admitted pathogenic r babyiitter; that soon after their departure a rax and shaken him violently: whiplash shakings b y ;ph& e , • l a , t h e i r l r164s •Aineri O t l . : 4 , 4 ; 1 0 g • o n Brain Damage From Whiplash-Shaking of Infantai6Caffey y e a s " " • • •••••••• l l o n a e r g
  • 5. , uise, cited above, have a special •angry adults in the commission o f i s r ••• • 1 -iiii,i1f0V4§saOlt•;;:0174Or. •••• ••• • - • • • • •••••••••• .• ••• ••••.••,••,•••••,:,,• • ••• • „ , • • Iômic1uavejy that even repeated mur- ,• • -:;,„•i.A1);•,tE,•••••,,•••6are whipped, beaten, and c a lv a ria o f t h e fi rs t we e ks e c é l e o r years without arousing the ordiriair•as well a infantsSk pe ad n, v •• supicions o f educated parents and • s • s • •a kaedny a r i * : : •h C a 1l-traied pediatricians, in an. opti- : ,,T h with:••;•••••••••••-;.• • ;versely e . • n :-f0 . r e - eoftment This long concealment was .•parently, many infants are andprior t h e in e v it a - s w f t u b , k ra e jp de nk i i o n e :t o the, fact that ,•to the seventh month o f life b •••s h s , • • • t shakrngs, which caused fatal brain :,le i b a a li e r- j o l t i n g O b damage and intracranial bleedings:in .h; a k e e e xursos patients, did not cause ,• one ••• p a r the w - nr l n a 8r r o e r a c p: t n • t h e • i w n u . d tfg ri o s e e o vigorous pathogenic shaking mayrr ht- in d u lg e d i n repeatedly fo r severT. v e a b , y l g f c u d •e t suggestive signs of head injury such • n n1 1 4 F 9 W • 0 C t : r 1 a tigaPie§ P ,P-,,, as • • l - h a z u n ti41:4:10: i 1o d . e , coughing, • - • , , • •• ,- • • ,, : , . , j a u r s : d o l 0 :P i, lO f O n : t a n e l. ; :tr us117 E ven , overvigorous "burp- "d P . . whining. - Oni 71, i: 1 : a , .performanc s 0 •d • , " est o y s a n al a r e 0 c r e a t ma e d M d • a e , c0 : 1- , s story e fat, n y prpn 0 v ant-,lash-shakes •a n ••wihk, ,•"t , netrated, in contraptions d h c jolts o yi the • b of the halio,d : 4 : tr . p ,younger t , n re s 4g7 and r):;f:ra e • •• 4g ould be p r e , e a r e r n - u 3 n i children re , n • cu ra,• ive • l v t e e, at • • g e0 ; ; ; • • l nurse.proCedures , ch requi,re •re- t e,, - )genicity, and banned • h o r vfa s i v e , : p : ot :•e• d , s, we i h ri • e et h e which can be observed wher- • peatedwhipl,ash-shaking and 3 • , •a •n a r l y juvenile use if it e , , ,an dp I 4 n a ye yPparents,eparent-substitutes, in - efof the head,oare: h , 7 s , • • tha p : ; j npath(); • e a y : p;r2 r e v a l O • •• r p ,pOtentially,, a •••••••• 1 genic t o t h e brain and should be e lle ct b 4 n S Over p i i:c e f , d t ,b andl small fants, u a 6 n 7h p irl, p rn e • y : • g i n r n d .: •ibanned or usedm a r With, proper caution. • pathogenic; • ;; These - ite s , e iurseries, d a y - c a r e , a , l a io A rtificial respiration •may induce ex- elude baby bouncers t t entersOrphanages, "preschool" • m - h ild re n ip g r n i c e • ny • cessiyely, high in,tracranial and intro.-, e r s,,and. f o•r y o u n ,4ih-,41 g r o•chogls, in parks;, playgrounds, shop-, 6 ocular, yen c , , p o u s o ri r •g e r • s 01, : • - , , , pressiireS , it c • ; :swin g s, seesaws, and playsldes - : hi e Pn themorrhagic brain i p te g a t e n iiepenterS;.andeyea,n t ••Ø , and eye damage a r r 9 ) S e i n ,e n t . in 1akinr e s t s- : . and pneumomallastmum. , l o " tory training a n d p r a P t e 4 a t , h t There are several apparentlyr , g7 y , , ••••••, , te : .ot f h e n responsible parents, who : :intentioned, i; • P a r k eet h e : : :, :• (•• ig, inkAiothhIg n t s n itC0 f a ;, cent,i accepted, habitual , praCtices, m?n, P O 4 rocking, horses, trampohus, t , powered 0 * • ; r, wea i t i n g ! , nnO ,••,• other than intentional shaking and a sliateboarde• arid ;Slecl•:3uni " s ,i ab", 0 0 7u ;, - !sliakings, n o t dream of giving jerkirig, which whiplash * O e d 4 and .:i•• S a i n e e t i i d i o s i i i i the head i ; •• •, • . : l e: § h l i l d„:•„„ s . ,of ;• brain, and which Could a a ,• !••". t k, ga v ti h i n g s . given t o j •oltmg transport-vehicle, s . A .• manent brain damage. The infantile i i * , carry infants and sinai! chil which.12 e. ; , , le a d , t o•••• aki head is r - subjected to some o f b these - dren--bieycleS • • :. *O !:::•,:pathogenic effects o f repeated 4 p e Xle , a , S P r i : •••:•: ?p e s n 7 s gm a stresses during such playful practices fi••••hides i a e : o .; c o n s d e y e -fi nl4k,! : l :, as repeated yigorous, "tossing, the r driven rapidly and habitually over x . ph lthe f - : :• : m••••roads of co ah y be m o r e graVi: -: callo r h 4 baby into the air"; ,"riding the horse," a trough o r • The recurrent exposur i i ot,, ePh" o geven i f heavy, b lo ws o r , in which the • infant faces the parent •:•••,1; t h e s h o tsingle, o .:or to•, daian plh O d i 1 while sitting, on, his pendulantnshin, o n y c l e e • - c •••• u om ngo hd " S .t greateStE•liaZardi;••*.,infari.01,. i ••;: l d aEsb a and the nature of the trau- 4 which i s swu n g , ventroclorsally; s n, o wei3R; g :and.,..hearingT1* p a t h O g e riic; • dtee itrauma l -n - , b,3olting;•:•••,whiplash • • p o t e n t ia lw•••• r„i, 1o ; : tw e used cannot usually be .• "cracking the whip," or gripping the • • a n d ; • : i.i z p „.a 0 h - r :p r .#1,#) infant by his ankles and swinging n ,c; i.h: bland yo u n g e r:,• ch ild re n r w i•;, -••,0401,,teck::: :fants ra in & e h 0 ana.:4,,Amnesia o f the perpetrators 1 him in a circle around the parents e p r :9 ed habitually:ini:speedbe,StS•07;qr p•he e ea t i sr • r ••••:•carri ,n d o. c. t ; , •, i r 4 we . •• head, o r spinning h im on his own a.••b l Y ,.:? 4 ,.tand in small airplane, im e ,: rough water • , sometimes lc0 ri h o r the kind and amount o f " longitudinal axis; and "skinning the :O • • • ,•,, rough weather•••::are"•:.:.•inanlf0StN•dia,e Vh n . T episode h s • o*ew i n g a is •••,••:,•and n •* f on o other, 4•• • • , ••••• • •• ,••••,•••,••• i..vp t •• •• • itviolence inflicted on the infAnt. Steele ; cat," in which the Younger, child : . p nl •, suddenly somersaulted:forward,r after y• peculiarly $ w • • tla o d n-hnsoi : ••: i.e .„,„„ t o 9 k, e k b rr a , ai n ta sf, r t a less d e f e i :t - or u 4 being gripped b y the wrists which r.,1,::i,•,.et•,i r r i : b h i ,; s , h sr forgettings i v e n have been inserted backward b e - •, . l : V it n a ; e •t i s u grabbing and gripping of an • tween h i s ; thighs: I n f a n t s t a r i d n . .i -h - l cgooh lr • The n •••• • soypk , e f ak a •, younger children are often handled ..• •moredp re v•a le n t i: . a re n n 4 . o A ca r k k l •t h • .co nl l itle a •• too roughly in play by older siblings any, la ., • high ,noise ;a n d , . a i r 4h h rn i ,iret a ,•• c well as parents, in such procedures •e„ : : possible , h i Mf s ::g•,e n 7; l 9 • -• as "shaking or sphming him dizzy." It u s is•„. , 4 , 0 n•tr* 1a tby ràdio television n hrid-.innsindueed . : as n a : aa . *• o !:o r ; •• g t,r • • y • • • t h e ; • • • • nd 4 - • iy i b r a t i o n ? : l e v e l * , ,e t: •• , 2 : e :y0Prr ,••; y • • • • 1: *r :. e: , , , . ,...„ • ••••••;.••••••,"..B r a i n Damage From Whiplash Shaking of Infants/Caffey I f 4 n •..; i s e e , a n d s O • •• • .w hbin- n g • • ••• , ” . • • . :3 o ay • tY n, p•• o h alA u ee i n : ok rrn •d e .: : :e •• i,b. j o o llA ih • i a ot •o o c e• . t u e lh l, f • ,b tc t g d • l - - : ammv x , ,451. b r
  • 6. , , , • • : callyu r a j hematomasa r e T 0 .7 S u d always traumatic In 4 , are found commonly- in i n f ants a younger than 24 months with a peak h incidence during the sixth month ctTh isi :h e litY o e it n b ill* P 0 1 5 h ik ilh a and . • i,• „e e i intracranial e . n e o n a bleeding is due to thc : 4 cQmbination oftheavym : • i fi f a n t i & r a u head andw , ,a t i c especially susceptible t o whiplash stresse4I1.6!1:.;hiC.,.t.1415,#.937 mem- branc;t1S; 0 , . a l a i I i mits e a y . . / $ . t r . •its •y ; i x . W h y : : , , h . o : *! .e : whiplashL..tractiOn:!...4**4044(ing ,, i I # k • : : : , b W .andl!ije 4 u nt,:rh :::§ 0 .4 4*0 *. rkin (h mature 4 i n y e l i n a t e a .*, 4 : : 0 • 0 , 0 * 4 y1 fit A it ire 0.t * i . cro pn a dthe subddial11740:49Ta is iti I)ta .1Wl, ! onset;.. of d s t o :usually uncertain during th e first l . ;1 i m - i weeksn di months of lif4 ,4 0 V0 o st ;0 i ; a and d t r natal trauma has long been depre -i e r - yp eiated because it has been undetected -I t ascribea::t o b irth in ju ry P re and mature infants are very vulnerable, n and the vi.fftiOabilitSi.iotfOlgt4ehl in- er •.* • • fants varie::inVeiselt*IthaggNfale ••: • •• • a infants are twice a syiillie ra h l , F i g 7.•LLarge bilateral porencephalic cavities. Top left and top right, Frontai projections b males; this is prObably,:,d40.it4:,,04 . at the seventh week. Bottom l eft and bottom right, Lateral projections two weeks later at i tive immaturity o f ; : M - t hs i t es of needle tracks in the cerebral hemispheres of an i nfant who had suffered from pi brains. The hyclrocephahc • • • • • l .,i•,.,meningitis at 7 weeks of age and who was subjected to "needling" of the brain to get the : , • • a:ausal, organism for optimal treatment. - 1infant is maximally:i.71.11.iietabl,e I 0,1 e - , • * f ,-t Infantile subdural hemat0Itafre , quently remains undiagnosed owing?,•amplified hi-fi sets, air-conditioners vere paroxysms of coughing, which in ;y -the customary lack; of clI004,0:tI telephones, vacuum cleaners, blend- turn leads to focal cerebral hemor- to i :,t and garbage disposal and dish- rhages and residual cerebral damage. diagnostic signs and ,S yt4 p t*Oe I : .T washing units may interfere with the Rhythmic whiplash habits of the in- graham and Matson.ph;e00,.ect: n- i h tory of. 4 i i i i l in ju rylp .p .n lY 2 § W 0 . 4 4 birth hasie rest needs of the infant in his fant himself during the first months ... their 319 patients, 6 , i i . d 1 own home when he is overexposed to of lif e, such as head-rolling, body - :04)0, , them continuously fo r long periods. rocking, a n d head-banging ma y be ,,0 jury in only 20%. In 5 4 7 t 4 4 4 nature of the trauma was and In small thin-walled apartments, ex- traumatically pathogenic to his brain .* : i ; .: determined.t Fractures o f cessive exposure of an infant to path- and its veins. Protracted, repeated se- 1 : : : identified ,in only 9 % . ; h O § O i0 4 were . o3fgenically high-level noises is practi- vere breat h-holding s pells ma y b e .W 40 bruises of the scalp and face:.w4.6. cally guaranteed. : ; similarly damaging to the brain. ,t sufficientlyt frequent to be included .ROg i* Some of the more violent forms of 1 Theoretically, the heads of infants : theirI tables 5 , I * si t i : a t a I i on clin ip I lfin 0 I 0 who suffer disorders characterized by clinical picture was notach a ra cte ri- ,:ii6t: : 1„ Jeated. convulsions I n tetanus, ep- immaturity of their calvaria such as :.m e ; a k 4 up mainly Of.:foyt;•1:00% it h t ewas made , I, ilepsy, o r o f meningoencephalitis osteogenesis imperfecta, familial hy- 0 ;, vomiting;: - vulsions, Oatised by viral infections or by lead perphosphatasemia, hypophosphata- sii0 .oe tability. These signs are a g , ; 0 * x -,poiponing, may induce traumatic whip- sia, lacunar skull, and cleidocranial ; fn lash-brain damage and mental retar- ; many ordinary infantile dj0,0,000 to : i:a n d dysostosis should all be specially vul- It 0 . *d dation , The grave, frequently fatal nerable to whiplash shaking. This is 41 is probablei that p ra ct ica llilA lt 0 , y p e r r r h the % , 4 cumulative s u b d ilk . a I , i4 smallo en9ephalopathy of infantile pertussis also true fo r the infantile disorders tomas which result f ro m i - !g results, in part, from increased intra- associated with weakness of the cer- shaking remain undiagnosect;perma-: ; h iO it *e cranial venous pressures caused by se- vical muscles. nently, and go on to OpOpme:; , , • ,n ,o16 1 9 7 2 ctiOr Brain Damage From W hi pl as 1) - , S hal su ;s i T l i l 9i : i nf At Ar n 3
  • 7. • ..,:.......:........ ;..,.• . . . . . . . . . su „ o , •••P•94i. in- .,.Mag ., , ra I ctraventricular fluid may in itself be a . . . . , •;.,„ ,.,!••,,,,••••,,,,„ ,••,,,,, ,,,;, g l)i,a n i e n . t . n 1 I Y i s . .. . . , patients, f o r„ the most part, were •;.;. extensive porencephaly•4041,1#airi,•: . w . 1 .tod ,•• • • :••.• • wio suffered from large chronic, destruction (Fig 7) Smith and Cro- itet#il oT4 ;4 e t a i associated with marked a ematomasd ,e d : : , r? .therar,f;haY.e. shown that the injection h i c n air into the lumbar subarachnoid h • : trophye fi the cerebral hemispheres 0 • *d of c i e n t 4 of Then g ineutence o:f mental retardation space rnay,cause • • :. : • n er , 15, d, ;did i tomas Overvigorous passive move- , patients is 4 : • •0 : a intrac: 4 ., i7 ...,...„ „....• ;•l d: •• t c, fi i a1 .t . ..:1(• c ,, .i: i x , , t ments ro f nt iha l in fa n tile head—to .:i.•;il::6. •o•• :•r :C.Ii::d i:il.. elw7.4I : .C•i.:4;:c,•i; :i,vi.if„t:,.h::,. li4,•e e a h e intracranial g a s a n d •!;:..• : 1;04•:ei; . ;.fl• C.•o : . J . . fi :.. :. t,t ;:. :,:....:: ,;t;o. .k. ,4 ; , t 1 ; t : . ; : . . i of adisplace t ••• .. ..• :i0 1 4 0 .. g,1:1 . " ( f t t the ,eniitin,i(Wrestrictedthk:nornial! • place it .in , b l e positions for diag- • e k l : optimal • h . 0 • tAfte::iAinderlying,:,, cerebral nosis—expose • : bridging veins to •t l i . b r : 9 e & : , the •::: . : , i: growth ,: 4 „ ,.,•,; :. i i d e• cortex, andc , • t t O . •• impaired mental growth , additional pathogenic:::stresses :: .. . 1 ; 0 , • • : . Chronic in fa n tile hydrocephalus .9a , , , ,••ak : i;1 ; ! ,7 k# 4 • . r • , . m ., 1,84nWeit, the membranes in a l un- P not been reported as a residual in :•. . ih e has .itain :d e t e , : .•.p . i • • • i p e I4 l. e MeT ct r " fants i n - #i0 •.a . i„.....,„„..of• e d ,. a :: , J a r : O ,. . a . n tt cases of s u b d u r a l hetnatorria,,k1::: . • . , : . .t!n greater number in , cases: of , , , ; . 4 noSed, untreated chronici subdural C ia p m Und a ;. ;.0 . • . • , „ • ,, . :•firta hematoma F o rd : gfound:::.. cerebral emon complication of infant abuse, it •::: p a • , I"... l ti ee - •.•" 4 0, : ,. . , :o: t i s t , and d e fi , i e n c y a n d dis possible t h a t residual h y d ro .! 0 i damage , c • • .:5!a .. .e n h ih ,t na u- ephalus has ; c . ;•.; „,. , 1 • .! t n , r1 r1 e e n : p r : , .t a t 0 t 0s b searched fo r in the currently avail- •. i : : • , .f•.„• , gi.,iii;treatittent. alone. One can reason- . s e ,rab ,:ably conclude that whiplash-shaking,. eable.,.,• r i t .. , , e ; ? .inadeqiiate•studies o f the late •. ):,* ;:• • .. j: : .1 : lii 0 4 i, r, ; W .sequels in shaken infants Cephahc ., h o , :• . .W t h and•:•;•Jerkini0, e ,: l i t 4 , no . ::.w , :t 1 :;,:npfas ,•,;e04p i :1 d ab U t : i . n t i . .f1 • :4 • • ., :. : 4 coj 1? : . f4 •s h y d r o - .. a * ..., , v e •::::•io.:.kiitiafi4o0,, ::•.;•i rela- e iosed cases, a re also substantial i c . g 0 4 may n o t , b e fipC r ;•,:•,e . r cephalus l : • stradiction ti : ;.:7, an eral weeks or months after birth, .( eg : , . : . t**4:.,O:iater.:nielita,l retardation in da .i : countless cases o f :,unrecognized ., i wsh 7c h : : : 0 i n t Mental :retardation occurred. i n • 4 e 4k : av .., .4 the , a . ! n o t e d ithe thigh probability that 0* . incidence in two small follow-up .which raises i n i L . . high • 24 : i a ,w r, e . :1 •i.h o some, ; r even :much, o f the hydro- ., i 0iy • . , .; , : , , , o! ; ; ; r r. , : . ia n : h "e a e l which has been attributed to .• • , , : I. .:e. th• cephalus :9 i: ,birth in ju ry actually, resulted fro m c•„ ifi • • a •, • • in fa n ts,,:•••• •i :, ;greater;:;40inber:Tlie.,,frequent 9 et s ae9i ar l i ti y h O m 1 ,•l • • ••• • • •& / ,•: .••:,, rp r :, 0 . • quotients „ . i I,):.: .iw l p Lictiye l m.u e plaah•-..-1,a4:1g a s t h e a•early postnatal whiplash-shaking u ltelligence,; , , ; : a of less than 80 :i.o :;1 e. f incidence of 12 in 2Z become n - n ,ej ri s group of 22• ii :.r .;#A00;„!:,...,*•hi r y•The studies of Laurie and Berne and ,mv e r . . 71 : • : , s i h T •• In - a: rObablef,,eause. •••••.:„ .n r : a fcreased to 17 in 22 (77%), t. one adds : ns fl u b d u ra l The retinal l e l -several others have demonstrated ): more:retarded children who were . ; , if r ,v :, ,five i3•. •- : i :i*ilt.tindeubtedlbeeelne valuable •that subarachnoid hemorrhage is an : 1 t :: r al n :-in !,, g :,i.. h e r n a t e .aIm-,• 1sip s . in* the diagnosis of subclinical •important cause of the hydrocephalus , inot availableffor interviews becanse cv i . : : sE g 1 .. . • s °• •„•••-: „p•••••••••„ § einapparent chronicaiibdural hema- a engendered by birth injury; this may 1 lthey had.already been admitted . l : oSO a sm • :i . . 16 •, : m ie l ,:: s d•be equally true for the postnatal in- . i . : O , i , :a, , : .•, 0 tnina . 4• ••i : : i , !:. . •••ta . : nt •14rerf;•„ ai c a l i § c i • ijuries caused by whiplash-shaking. 9•:• ., a •• t Russel states t h a t t h e hydro- ,• ..d4 ..#41W4):i a: b oi b40eeriinetpst for : : 0 , , i,•• ional j *. If i i i i y i . 6; /TI • A,! ::lOn;:iiidother types of so-called idio- w . ..r ly low IQs.:::111orsefl„ef•:41:ifOtin• ;•••;;Ji ,. :. ., lenot•. .b, h o: tts e h a . d cephalus-producing g lio sis o f t h e ; brain which follows hemorrhages is so .0•• ia c i d e. n c e •• e . . •. n g 41 : • •t••••:,•,,ede in de b 4 l ra tal a t - , ik damage i f f n a .d :::a nd i ri e n b e ssimilar microscopically to the hydro,- ,.f :: . : , ,I ,60% l „n ... 1 .",.. : • 0 o .§ •o i e .pa s b ra . l . r. arotea,ux cephalus-producing gliosis which fol- • .:fo w e d ,. . . . E :e l . . 0 :; ..f. , ry Kempe e t a.l reported lows infections that the two cannot .:tp.•s in jud. r o .. : • a a e l i * e ,oq tdta n t . ole t• ermanent n . nal , . . • o satisfactorily differentiated. The ;dI. e .damage in 25 of 45:i,•••••con,/ b n .t , h c h i l e i . r ,ym,sr eev a l e n clesions In; tY ,icl,”,a. e PP4,1e, retinal e re ba ic r i a be i. brainh r e:e Y.4i . m.O rnt t a l .. , irt " : / : fatal case, r ap t !n hr n f o h tobstructing subependymal g lio sis :Noen . .c 1:. : which surrounds the aqueductus ce- .t r*oaliriaia i:th e4 ;.: e: i ireports suggest that•permanentimon oo eo 5, n / 4t;,•,•• n ders iei l fa e; ssocti f d1 e0a0li In p a rebri and caues the most common a 1 , 9 i„oithreed a f i o n . e,.tn r . t 9 , .t a . r • ,ill of i• d ..ema- frbp eu a riendlyvt f ie n t r - etype ar ,lbo , associated :. qb•!i ; i i • f b4ra ,§ ni .dainage:;,and.Enienaletard4ttif .:e •ci i t 4! ,g r! o . l.r y• ileti.?:074 n- li a taat a a l ; :rr di l r infanof ventricular hydrocephalus in :drgnumbçr .n : . a t i.p vsli.of . einh . infants in s a n p .: og us :4 : i ietual qpende o r hemorrhage-dependent 1r•.. • u. s e •• • b• .i ihR been detected Mo re detailed • rt al tds: -i a , I t. 40:014dbebo.rne.io., r i e nt . as .t °: : 0 * , : • i4 i . 0 : : l pp n - 7 a, : o P uThe same is true fo r the neuroglial •••••• „,•d• • • • • • •.•,•• ;: ,b.:.: • • „ a :. • a • : 4iron- r"or l m s a 4 • • • •: - •••:•:•:.;:••••••••••,••••••:.:•••••• .: ,. P t b • . .. ••••••:.;,.•••::;:•:•••:::.:.„.:••:;:•••••• • • • • •• • • • • . „ • h ,,:f ie mel e d i am a •:•••• i „,...„,„,.„.. e a u dm c d e v •••••-•:• •, ;•: • •, .: . . , • : . . 1t .•• :• •:• • .: , t trsai g s C h i l d e ty ., • s . e: iien v e e Amer ri , i ••• , ••„1•••:•••• • . 1 ty . • ••;•:•,.: :••••,;•• Drain Damage:. Frein:Whipiaehlshaldi4:eftnfainglp,a, j4:0• •6i -i m... l . . 4. eb • sn i lw V ool d / e i ; . .•.•.- , :, , mT • : . , o an • o le • • •• • •• •••• ••• • • , . , • • • • • ..••:•••••Y ; :" ,• , i • i , i g nn ? A 1 d • • •• •• • • • • : ): . . . /• , • • • • • •• • • •••• • • • • • • • • • • • • • • • • • • • • •• • • • • • .• .• • • • • • • ..,• • • • • • .• .• • .: ,h • . • • • tf t ye i , r •. 0. . . 7 • .f. i ne d" A nu gd . , • ••••• • . . • • •••••••• c d e . o, . u t h •• • , • -4, , • , •e . : : , • .r i i h , a , - g h t . -••- „ • • • : ,,,,,,, 4 . , • • 7 , i, .,s •.
  • 8. a id from the cumulative effects of,riumer- sistently depreCiated,anCl , , lOrt,of the true incidence. otis, milder, repeated jabs which jolt , The ,radiograPli,i01),Oriepcbane c araCteristic, consistent st ru c, his ibrain. I f one cared, to paraphrase the PITS both t1 ie i-a opr, oen: changes , in , the brain haveidio- • the cruel but ,realistic, lingo, of the tribution indicate that they. areu not demonstrated in so-called fight game, one Could accurately de- 4113 n hic juvenile Mental retardation, scribe, some mentally retarded , chil- handling Of the a r m s , t iCh includes 8,0%,tO 00% Of all cases. r dren as "jolt-dolts”: or whiplash-silly.„ legs, such as grabbing a n , ti o the •eas l, • ca , T h e exact ,prevalence of idiopathic grasping,:is4neelin0:e*iniln us raldifijuries, it is Possible that the juvenile, mental retardation , in the jerking, and then whiplash-shak se original,i e a rlyt ra u ma t ic cerebral general child population is not known ofd head;,all o c aw h e the e rdp l a but all r e s p o n s i b l absence of bruises in the skin:of . c u r subdural hernatornas, the petechial e es h - that it is woefully, high—as high as 2 : arms and :leg e •• :, s. • h millionm a t ein persons younger than l Several : mn s h a , e s t i cases s ebral e , contusions have all disappeared 1 ,8 ,y e a rs . a e k i n by the time years later, i n at 0.5(io T e e percept, to I A je rkin g ; o f : t h e je X t re in it i a: m mpletely • set d i c a t n 4. t eg , %:, . e X o ,e;:,,brains are available for autopsy. , of children in large metropolitan Cen- been r e c o r d e d lash-shaking r o The g a Owingt h d c o the frequent lack of com ters have been classified as Mentally e k* r nw0l t4ep0: , P r arahle degrees of structural changes subnormal. I t is obvious that, if the .e e s 4 ; - e • r a t e f . ; ,: i Wh ih ine e brains of children who are se- r the * dr whiplash-shaking of infants is even a teedlfiat s e l p y t b d u r i , :l O tin:,alllevels 0 p A :h vh ruiner cause of such a pervasive and variety!ctpersons,;:jn60M4077 n g , • a y p aa y- ef e suggested that the original injuries a devastating disorder, its prevention of t b fo r a wide variety of ri i n f i:b s v a k i l U- irreversible change i n the ways, r o sed would eliminate substantial amounts : h g a n c l enrone, themselves changes which • of massive human suffering and mis- yog g n er y :r The pathogenicity of„ordifia, , re not detectable microscopically or e ery, as we ll as monumental socio- ual, habitual, customary, repeate : ls d , ernically, i ,o economic wastage. I f one assumes shaking of infants is gerierali*Unre ce i s , y he cerebral lesions of whiplash- , s 0 1 1 iO4 C# that the average family unit for each ,ognized by physicians",and,pge,n, ut uw i malcen Children have not been studied a retarded child includes two parents 0 The infantile head iS:eapecialIY,,vrJ mdteniatically. I n some studies o f g ee n and two siblings we can then appre- . d e o wiri u Ufit• traumatic hl y ciate that the lives of 8 to 10 million a combination of ;4e,: •( nr d k ,t p „41./1: g t l e changes in the brain have d if- i additional humans are dwarfed and ly heavy headarid,WeakneCkninSeje t ,n • •, , • , fe iun j u r i e a .n darkened by this most baneful of all to the plasticity of an immature, par av from those in older infants, children, chronic huma n scourges—juyenile d g•:• n : est "inenibrafinuS: CalVarinin, and , le - and adults. Diffuse gliosis was com- mental retardation. , the SoftrieSs ri t , : : mln o Cerebral palsies and idiopathic eP7 .inyeliriated,hrain. e v , ht o h yt ilepsy appear to be due to postnatal ;•,•. . orhe;:,perhaps , 1 d e ,Matie cerebral edema and hemor- trauma in many case, especially in • 1;rovascular injuries which are cur ae n,c of a n n , .m a y rh s vh those cases in which the clinical signs rently, attributed,, notk•CllniCAV ieentale oi r f i m ih h ea deficiency and motor defects first appear weeks, months, and years : r n • he due,to the destruction of the after birth. I t is probable that post- microscopically, t o prenataV4ifi , plak d t tions,hl r e ; l , t e a t i congenital ma lf o ra t io n n bg a r e m ta h,,, natal whiplash-shaking plays an im- birth A c injuries, m e t a b o l j e r en g o tricle. a h ir The most striking documented clin- portant causal role Neither o f many diseases are undptibtedlYeaOsek,,,, in some or ie e n ts e g of these patients. these undetected, depreCiatediand:: n i and pathologic example of mental disorders has yet been reported as re- :n fi . ical r y parent w hi pl a s h-s ha k i ngs b ,iec tdeficiency, induced by repeated whip- sidual effects in the PITS. More, and first weeks and months of T x oer - ,: lc h more comprehensive, studies a r e In the follow-up studies needed to determine the causal sig- :, or4groups, of:, :pre y i ous l y c uec associated w i th profuse petechial • 4 ;4 ae small he n nificance of whiplash injuries to the f,ja c h i l d r e n se n r alled punch-drunk or slap-happy vet- infantile brain, in residual cerebral , . a tized c elr g was found to hair,e4 surprisingly higi hran,, fi s t et u : :;ra ni na . m palsies and idiopathic epilepsy* ,e l- incidence. The,mental statiisOtthed „l- st nie nta l: :re os Summary and Conclusions patients was not de te rri l i ne d jy efi g h tof r ments e judgment with speech and ih their 4 0 , 0 t 4 , traumatic abuse. r, t .. go. rbi Shaking is generally disregarded as The evidence on whickOiit cOriCept d adly, jabbed and beaten over the head a type of causal violence in the PITS 2 pl i 0 :t c r la eHn r of the pathogenicity of infant4dha u ih tr dnring y s by both parents and physicians and it ing is based d o e,lae ;ring; He may never suffer detect- is rarely mentioned in medical his- satisfactory statistical ,s g i ta e, acute, brain injury from a single o o :: lp od e gu i tories. Thus, both its frequency and versa!" samples of a y e ,tu sv e blow; he does suffer, however, potential pathogenicity a r e co n - . ; t ioi t a l o of : i e infants: have notbeeif • eeavy n a rs d . shaken - sol o fn i is ots s ep d g n •....„.• pI e n pc u; :l: :a : t ( o . t l ia t : • ••.: i ao fWhiplash-Shaking of Infants/Ca fh s sse t ,....: • ••••,.,.• ,:.,••••• •• • • :••••• • •• ( orn ,l n a nh n . e x ter oe ro 1 p utd e h- fli u . rm s oh el min e t a 0 u b r af i e t
  • 9. * C tl „ f - g e tw , i " .6iges inr 6 . Trauma is the most finfants and d is I o c a t io n s . Brit J Radio- o p c d n a r e l i km •Orde c hildren and i t warrant s aggieS$, : t preusu- : •• 1Whiplash-shakmg of the infan- , study to insure effective preventive t h e diagnosis of traumatic injury w, iii .. , : o 9 4004i s i#Iii0.V; „ optimal 1 • r ,genc to some degree I t s actual mci- •• ..Lth e n 0 eice is inknown and cannot be even t soon f 1 , 4 9: 4f 5•1: • P6 4 4 r.ge0.4gt ,estithted satisfactorily c li#0 a : .4410,0e# 0 2 Whiplash-shaking appears to be : • 6.; :•.,•:b.eacttrannia•Uamin,thelargned::::!..dr9e).(hattered: h h n . • s••"•; e ma i i s;•; : : , , , : t, , v lclnc 4 ,praetLced widely in all levels of soci- • e , : ! • : • ••-•• • •• of * fo r many different reasons I t is p itraumatic thSpa.,seS, with the 44;70•Su0 ety n lrnm g „ • ••• • •••••: . . ,.•. , •, •: •••0 - ( e ira lly igiored by physicians e •; ; a$Othe.r • • • • • • • • • • • d , r 1 : t 4 „ ,;••••.:i ,:- :a l r e a •••••••b 4POi. : Al ri ad • o • deft- neopasms, metabolics, : h : • , smal c „h i l d r .e nj, sg r e n f o y d u t ty r• • ••••• ciency; -• • ,genetically determined and w0:i„j49;w:igve é * : 0 ,CY:Y;41.whiplash-sh V . 0 k • , . ae e a s. 1 4 h r da K al i, c•••:eases., ., , C• a f , f e y• • •diS 3 • • • i 61 (; - hOdi Versity Of ChidagQ„-y e, Sa, l i.e V I ,.:•, : J; The:problem and the prevention of t • • • :•••- ••, a :i , : l1 : , 1 4 0 . 0 . c k , kings.i : i F h whiplash injuries are ,summarized . n .f ;u. piiitcipia•; and i t S 1 j 7 I injUrlea;::;.0rifilliedfJ•;•2t43043F1971 k ,• : i I I lc 0 ro, • the following quatrain • g - . . ;R , 19i5i F4 e14 t i ; 17C r e l a t i O J S 4 4 Ui. a#6 &g 4 0 4 1 4 7 4 : 40fa : • Hark ye, flood parents, to my words true . : ,et , The o 0, , : 4E; s al: n ttle1 n, 0 1 2 and plain, • , , • t , :" ah i t iM , A: 1 p0 s*ladlitik La Spine P spinal cor E A O and P i4.h: 4, , : • : , E , : : j ! a h t c 4 When you are shaking Yourhbaby, you , 1ei1 , 3 • ,4 Ke: ,T64 , , ...:••;:,•,,,t,h.!:•!..re . 1 5 : i oS . . tra*a..,:,inthe battered chiltiV:,•,SY,1•1 et4 i .,:c;r:4,!, n P: ; co e rr ah 2 , could be bruising his brain. • • • , 0 ;* V h i P 1 4 SOFT .1 k f e I / 1#0,0 n a h e ? z i a it . cP , : les atilt, b e c i„ So, save the limbs, 1t( , 1 Childhood J AM4 199:10,3,16,5;;;:4907! ;; !s: 4p ; o k t 1 r , ir s unrecognized , • o f your tot;,, r •• inf i le , , :_ , , y n d o f , t :C , t h e , cId .b::f 10a i;a Oii l i i .l :-I49e4yi,,,....i ate ment al # ;;M •, X1i• l 4. : * • i i i l consolCilous fqetut . 11, a b ru n s eu By shaking him never,, never and not. • , ei • i MJ Fundi of tlatterekha ie Sents :, ia . si erne r ab i n;h b r ia i n , , , 1 t 0 . h c e 0 "v. of Colorado, „ e n a• f : er *44J 0V 4, l y : m: os r e u : : versity made available data -ingt o b0 n, , ,:1114yt , t a tfrom h new book Helping the Battered • M ! : of in- , his e t, !j Sprin e ilf : 0.; ,i a l per o .0 a ak ) r r,i , 0 g lChildi and f Family (J. 13. Lippincott Co)ʻ :;:i:•,:14*FOrCF,R!:.DiS•04i S::; l , 1,p e Its 0 , e Uk•••,.Ner;.,//iiscJe f, i : ma n e se : • o In: chapter 7, by Harold Martin,42 abased •• i : P n g SYeteM i* 1:hfiiizc,;,01,4: e a,44: ,rr : 1 nt - A ,e A ! . , •t _ S : yO ;:•• WA ,• SpringtOk•WpiarleS ,o i C 4 • P children were followed for three years He nfraries to Oe, d 4 c ,: e e ,r field , Rmd to #,41:044e si,:, d., 11e3r, , are naostw:ihnusually • ,, e ,:, , b s t M , r found 33% functionally retarded; pw; , or • 0I . ej, I i4 ,T h ta c o n e these had a history of trauma- to the head; • aoh i c ! 7h . • o A i i , ,, tyr a c t i o n E . • ,: t§• n 0 . : ; o , d ..„, . d0 , q • ,. e4,:c071,0;1:::::494 Subdural hematomas or skull fractures • : 0l0 1 l d N Cl * , . s urn 4 i were found in 31% and 43% had neurologic , , 2,i a ibabies, Pir0s4/IfitV.7571,1:,:<19.6tk., ,terett loi : core- f, as, whiplash-shaking of s T . h residuals Dr. Martin points out the corn- , • : :,:r child abuse.ATraii,Aiii3Ot46aCO ,o w , a p t i t l eur- - r : n , - :- • 4k of : , i,. ,0, , n e :aAi0 f •,.10446.*4"41rMili JOi,;•,i0ay.:::i0iiCeo 79 , plexities and interfering factors i n • at, : 1P4 / Dr iOtolaryng deceleration:pd:::::: and frequent b ilit - 1 tempting to establish exactly the amount; : 4, • • 2 . : 75: 318-332; 1g1t , , , : d vy p : 0 6,,: 9 of ,permanent brain damage and mental .. aa18. Lorber J, Granger:It, i ; C e iinfec- a *0 , T , _ i : .• t: h : .: 8r ?, :following ventriculatpunctur• , iities C hi t Radiot 1498-109, 1963.:,:,::, : 7 ;2 4 i1t,, , , 3 0 : 3 fants. f Of Such signs Of impact 6 , retardation, which results directly, from • .e l: ,,: 19•, „••, •••• aea, l f :i r : ,ce•:,• •:abolic n to ,f h , e C 5 traumatic abuse , • , l ,. , ; , : i l , q K : : .. • ,,mdby 4 ua , a Us asr b lnn s to the head , , .A comprehensive and authoritative hiog- :1.:::0:;(. ,a .k 0 a r oo o ,,: , -1n;1;: . . alography. Pediat r 4 :h iscid,; 1 Ei caused pe c p • raphy of Abraham Jacobi by J. S. Leopold :f9t 20. h , 7;: /iSmit 111;map- e ltl y b lo :, the etiology and-pathogenesis of ,0O - h minv7rn, 9 n , n o fractures o e t , on• , g, : p can be found in Borden Veeders Pediatric ; 64I, I :T, , communicating„hydroCePhalksi.!Th H :I , l 1sg the soe 4 sca lp w s ,; g: i ! h h t ;t i 1 , Profiles, (C. V. Moby Co, 1957). „• e , ic L genital :; .ldsyndrome of delaY0c1•Jimprrhagiat42:: 7, t - P1:ʻ 7 : e •,S,riarnP s 4r ,m :,•:gi : 3 7 5 , the transverse cerebral fissure 5 cisterns of 3 8 0 • two ;v•• • ! t eieb iS There is considerable manif es t 7 n r.9.a ants. Ne u r o l o g y i l . § : a 1 : 5 •i, 9*muma- ,r p,• m t e , - Drs. a, n 1P u Of,inf r Bertram Girdany and Albert B. Ferguson; eth. r Russel D S : : : , 0 o d ad „1 C 9o t 5 0 . i:;h 21„ ;ftati on p u a• , b r e n ho,-„indicates t hat whiplash-shak- 1 generously provided much excellent radiographic .stlio/ogy of y r ; nseriesa 0 6•5 M: , e, ; • t e o r and clinical material from the departments of ::• ,.n 3 grZ1", : Medical :Research COUnCOLO : 4 . t , e 265, : p a r i ,s o K arai 0 radiology (Dr. Girdany) and orthopedic surgery ,d0 4 a 0 r imajesty* ;Stationery Office, 0 . Her * t f , O a , • r ru i :140,./,?Ild ,jelting,, of inf ant ile heads 0 (Dr. Ferguson), Childrens Hospital o f Pitts- . c1n gA„: Elmer E: Chitclre*/,74;::•Je0Ordie don, _ k .: n k s ts be major, unrecognized causes of burgh, may e .l ,, ,e, i g . 4 1 • * : ! , : gen n, b retardation and permanent . , i,,t O ••oStudy : of Abused MinorelancVT,heiif;170*„:, ,k,1 4 ,:Pittsburgh, VniVersity::!ifl:Pitt,ShP4hp, • • d a t i m f mental u ie ; s: i p ,:yt 1 , .. •,lies. : nPresS;;:.1967. ? 1 : i ,l, i n , b .i;t, ,1„ 2 * i: :..00Pt4,0 ts e p e . s. i 23.; Morse Oiv.:;:, Sahler•:(MK:: Friedma :shak- tyabi,tual, Whiplash-shaking for trivial fi: . m gn , , • • :References :.,SB:SA O : ; ; ., . three-yearstlid4og, a...boocti 0 4 * .h -d h r a h sr reasons warrants, a massive nat ion e e t: B l 1 n :.: glected children ;::• A • ,. toif h 1t jo a wide educational campaign to, alert t•a • e D .Sla, ;i : i; 120439- 44, 1970: : ; ” :: "• : - m4i r ,l y011O. responsible for the welfare , th e ••q2 ;4 . Christy RA:: b _ ,,, :• e ; at2„, o0,Yer i ai 4cinfants on its potential and actual • • U N Y M • i ., .:u •: ; •••: ; : the ,.M:Report of •; : , American AcademY;;Ot: !? ?r? „ ,1. Childien::,1970 pi G , ,::,:::::, ::,•,•,":,•••••:,••::;:,::;,•••" ,ation U l, of • h•,„,, , , o . , •,,,. , , , n al946. 4 -n a u r n a l ? r suffer :"d.ii: t:atria* on the Delivery of lgei,;iial.:!M„t e: : , o s. : h ,pathogenicity • • •,, • • r ,••-,, •,• •;s •- uau3ln , „ , ing • e L •:, n g t h e n O ; ,a,e 9p:i nr W : • ; 4 . 1 • • • • • : , ih : c • t i2 f r n ,,u: . eg: p .:, , ,.4 t „ „ „ „ - ,i p 1 e • l a , !rc , Xh0::•: a, ,: ,d ! , , , , , : ,,, ,,, ; S:•1A 0: ". , ,•••••, . , - n :i i affey i, e rilef, :, i?e •Child/Vol,124; Aug 1972 • , • •• • • Brain Damage From Whiplash-Shaking of n f ig n 1h o e *, ,1k S o :: : .a: m , r - ʻ,•, ,,;, ,- , , , , • • „ , a ; t m t:O :, . •••••: :i 4 l 11.4 o: c (d . e;7 ,f i t u l s ::: ,; 0 l :; a:: k : c ,d ra c : s : •, „ _ ri m e 1 u • a - e 1e . ;, w 04:,