I q fea-s c4 1

0andu411-

Inceo

twit

Y-Tai

Atiguat.19721;,Vol 124 No 2•

.e9 S

.„ •Its Potential Residual , •Etlec t s

,.„. .,•• • ••,•,•„,of 0 . t r # 0 4 p i i t,. • B i * i t i : • ' D O• r n a g e : • : 0„ n c t : : ; • M O k it 0 , 1 : ; • : : I t e . i4 t d a t i : 9

• • • , • • • • • • • • • , ,•1

.J.04::c4freigp;•:: pitt§buitk•:••

'

Abrah

-rn the first modemdiscussion

in 1946 of the paient infant stresssyn t i rb * e t •:: (P yRS ), o r b a t te r e d b ab y

syneir:§00';',*4esci7ihecl: s i x i n f a n t s , 1 3

months o r younger, who s u f fer e d , •tiom the combination o f subduralhi matomas and characteristic bonelcsLons' During the last 25(..yearssa t t g a n t : l ia ke y id e rie ; ' ,:b o t b ; " , M.a t l i t e s t

sad circumstantial, has gradual* a6;:'cumuIateCivhick:: suggests': tb4,.:::the'whli4lObiabaking.:•,::: and je rking:, o fibused infants are common .c a u s ' e tthe sr0100.10,4):•;*.01; aa.;.the'eerehro:': ,vascatArte0Oti§;,,tle I a t t e r i S ! , th e m o st

s er1o144 ' 0 ; c i t 4e•,011: iP l ic a t ic k p l, a n d L, f a r

the mos t common cause o f

g9#0;YAWeinvite your agOnt,ion,!,tn.••the evidence which supports our con-

cept t h a t : ; , : : : t h :,: t v h i O a s h 4 a h ak I n g , a nd

jerkmg o f t i n t s are frequently E:pathogenic and o f t e t l.::re sn i t i n g r a $ : : ' ,

permanent d a ma g e t o i n f a n t i l ebrains andeyes We 041 also rppu4':

out t l ia t : i i i . o p i i t ia l ly ,,1 3 : a 0 io g q i i , c

: ,

eceived for publication, Apr i l 12 1972,,ac.r . , . • ;

: :

p i i * t he departments of radiology : and peldiatiiii;:School of Medicine, University of Pitts-bilitli,"faiid the Children's Hospital of Pittsburgh,Pittsburgh

Read as the Tenth Annual Abraham Jaeabl',Aiiy)**FlOaaaif before.:: the 121st annual :conv e # i i i i kr. . o t t i o : :: A M e.i i c a t i M ed i ca l A ss op l at i ow ,

Sa. ) t i anc i §:c O; : . , l ar i q 2 0 , 1 9 7 2.

Reprint requests to chi ldren' ; Hospital

Pittsburgh 125 De Sete Si, Pittsburgh 15212:- C 4 f r e W-"

Amer

"Pr

rtN4 -

•

•

lash-shaking is practiced, commonly in,a Wide variety of Weis; Under a widevariety of circumstances, by a ',w i d e , ,variety of person's, for a 'ytride,jrai:iey„,of reasons:: T h e m o st c om mo n m ot iv e

fOi', repeated WhiPlaahahakinge,f,',i n -fants and young' children is to correctMinor miabeh av ion Such sh ikings are •generally; c o n si d e re d i n no cu ou s ,b3 r,

both parents : and 'physicians. :If ,, , o u rconcept / of the pathogenie,' signifi-cance of whiplash-shaking, is valid, itfollows that the prevention o f suchshaking and jerking might substan-tially reduce the incidence of braindamage and mental retardatien. The , •

l i i t e ,ö f e•••I

genie vaalcil;umenaornZhogpentiv:sehlkpillgh?;

often h d i s t r i b u tio n ITS m u s t b e i n _C

;aigotnur.seinom ant!Idp strsibyustt,omnat,o1:::::

bone lesions „ t h

:atrrroePptrshey:. se xe cr u ss veaeciplyhiyh s'5becausestaehoeosr:ohci,

chaSpact a0/ a:anorll. rvemretei a f fe c te d,

ot'sneh' ateloe'rbr7Intwroett' sntthobas:seseeleuemdltaer', lenosen common

t iVtnheef ragment satlieuniprit;Ilee: d4 -• • exploration

orml aoir r sypc:tt6tihoalbto 'aloerehaoni the direct, te7a 'huh ts' I tmq'n4eie:si avulsions

e n c . ' stretching, 9es' : e . ex l 1 " 'el ) °f1 ' 1 1 I )

d irect,s h ea r in g , 1114 23 her '

fragments

.oste

alavu lsions

,om n tonly a n o f

-

Traumaticace d in volve h e . e h y s e

c u l s m eav segment rn io s n

bone

16hre:1:eieneitne:irhsthlaad. ::ttsentOo'2 capsules, lfnoro' utrv' :IdWweto' ln6onihqnv'Psee:skeibste::' sareteari stlioehrr' 66uti p ro v is io na l sh l i f a i t h ' t h e h ' u x r h u ce l z 6 s t e l :1 3 r i u 6' i t e s ap p e ar

fiaas911 )(peoal 312 rdotsi:oflielC:4gP c ap su le s .ta ' e sa ee ' aat tachtvr c l( ti l emgF1 So ji f ' ici ril si agtgi hg•( )1 ' r

minal t TY:11:1

sheass s on , c a s , t

ffee- these 'pemae;,to,irr tchkip ie ' r ,a t t t_

m t r actio n , ,

Dip ,Philci/VoI,124,, Aug'1972' Damage from WhiplaskShaking•of 'Iirifant0Caffey 1 6 1

•••4t,

F-U

metaphyseal fr ag-.merite:ii:.(arrows) of the provisional zone of

Celaticationi (pzc) on the proximal t i de of, : ,thQkneei in the femur and the distal side of

the tibia of a patient 4, months;ii,' o f-e e, i,. . iv _h ps ei pe re nt s denied

_ ••• ••„•,, ••••••••••,„••• „..,..,..,•:,„ ,:•••• ••••• • ,•• • • •• • • • • • , • ,-Aug 1972

11'

-

• ••„ •••• •• •

, , , • ,•

U s u a l l y They are the largest and most con-spicuous of all t i anmatic lesions ingrowing bones t h e y are notfracture-dependent They develop dueto traction-rupture of the abundantnormal p e rfOra t in g " : ;b lo o d-: : : ve sse li,-" • ' :

which course througif.,thelettotieal•Valt-„hetVieen'•ithe:Parosten't.ii.,•lantt:thmed-

ullary cavity and -ivIlicli'•047.0.:,0'0„.iier•Oct...47:•;':,the junction • .0.10:„Inten.a:',..:'•e'cike",:ofii

• •:,• • :of blood internal to tne perieetetiM'i

,,,_•,•.••••• • : • • • • • • • • •• •••butextern41, t h 0 , co r t i c al ••• ••••• • •... • • • • • •

the Periosteurn.off;:.the•••wall-.:'!,fOr.;

able: distances and I oii n , *teallImatp.mas•Of vanable sizes and• • • :;••:,

•••• . : ehappa„-: O f t e n t h e s e:. a r e,. . . . . . S y na M O r i e ai : ,,; , . ':

in analogous. bones. la. the tivo 'artriS-Or:::-• :.

•• • ,• " • • • : _ •••••• • ",• •• •••• • ,:•••,•legs;„ or they affeet, bones in the aims.•- and forearms:: o n l y, o r s o m e t ir n o S l l in:• • • : •-

• •• • •• • • • • ••• • • • •• • : • •• • •••• ••„.„: : • :• , the*, t h ig hs shanks only Only„;:•::

Fre-quently i n y o l y e." . . , b 0 ,0 0 s2: • . . o n b o t h : • •• : : .

the distal.. p ro x ima l ' ' , sides o fointl,, e sp ec ia ll y, Oiel knees',."

••,_ ,•••_ -• „ . • , • •_•,•-•:fi r t t h cy appear radiographically

, s u p e i: - • •imposed on the haft, but after four-W;0•4'....,d4i4,'.:;:',.4:i„Ui!'pactile shell of new

:.....,":.:#breUk:).00.0.:0ii!.0e.fe form around

. . . . : : : • ' •:t t l e . . :4 4 0 t . n o, V.: 0 4 k O 4:: 4 h e hem a to rn a.

The entrapped subperiosteal b1oo;then::gradually resorbeci The n a 444and distribition of these lesionsbe c a nbest explained on the basis of i 1? (1 i-

joint:•_,:•••'•,_ • c a'- P - s - ,1 11 :1 11

:a -

ti0k4r0t,f,0*d.;*gi*iithOperiostetlm.„its vessels, and thefrpOinannalgeizi14'iliAtilppitig., , , „ „ „w h i p l a

h s h a 1-

extremities and head ,Neither th e i r n a t u r e n o t ;

distribution can be -, satisfactoi i1y

plained on the basis of vrect stresses (blows) on the bone _et:;•:Prt

itsSeveral observers have noted

c ia t e d " , d i f f t ise lS lO r.O.•4 : ,-O t t h O S h a ; t S' °o f

some o f : ' : . . . t1. -WA IT* e . i ,U. : ' .1 t i o n OS ' i § f S o me Fp

abused infants Th is has suggestod i 4•excessively fragile,:brittle, chalk-like_

: bones to ec!Mp',. r a d i o l o gi s t s I n r e ce n t

ll.:.-.1•Diopsi:eshd*ever;iiiitfleiiii,jCriiiedpic ex-

:b e:amination:disclosed,)voven pat-

exces-

, ' ' , • ,

, , • , , ' • , ,, , , , • • • • . • ,

,;,::;;.....,:,'...,1', 1:::::,"::::',.::::::' :•:, :' •„:„,.; E::';::,',•:::'::::;;:::,,ll, :,:::,:, : :, J., ••• ; : :: : i ',... ; :: .:.. ',,:: ::::•:: •:. •••:',..: ...... ,: ;.:: :•::::-. ::::: , ::;:::::::,:::::,•.....•:::,, , i ::, i :::

' : • • • : ' : : ' ': '''':•;•- ' ' •- " ''''sive: newly•: : ; f o r i n e d ' : r i n i t t i V e ',5 A b r o u s

:,,:l.,-:::-l'.•1',.:,l.•;-,1-:,,q•-•::::lc•--::: ;-.; ,--' •'.:••:': i',";:•-:.: ::•• :: : : : : : : :; : : : : :•: ': ;: -,' :::'• :: •• , ; -1, : , : : : : ...: :":' ;-. ::'•,.::::: '•,•„:i: ,•• ::: 1; : ::, :or' woven hone, which). foitn-iiʻ•Wkularly

under the perlosteOrn" f5.Fig::•.g: -S ym me t ri ca l metaphyseal "angle" fragments in the edges,of,the 04c of ocok; f ei .:- ,: •• •••-• ';., ,, ni at ic ., subpe rj oseaL iedemk ,o r, bleed

rn -ur,& with . ,, -. . f r A r nn t s in t he m ed ia l edges of the tibial pzc. A faint d

O e, loop , : ,.,.': :: :

_ ___;;;..,,;.:::::;:.; ?....,..::.,:::::,.;. .:::::„: :: : : :.: ,„.::,;:.. ,.,;,: .:::• :::: .;: ,...„ : ,: : ; ,: .:: .; ,,..:: : .,. : „.„.;•,....:, :, ,:,...:•:: ::::":•;' ! " ' „,_ " • • " . " '• . • • „! ; , : , l. * .114*i: , : ings ofe ,.. l l in -

a

_: , : „ t o m-l i t y a fi n e . i n g o r b o t h . T r a u m a t i c „

opaque: curve d l ine (arr i74/4/s)is s u p e r i m p o s e d o n i t h e e p i p h y si s o f t he r igh i 1, l a. , ,:,

:,.,„-• , • : the external su b p e riu S t:e a 1:; ,# 0: o f t h e

thickenings

,,,iit _.; ,„,-, _• 4 ii,: i! ,: :, ., .? ,, - , ,, .is,,,, , , cortical wall are the cags.e::•:',,9f,', .'•,c_•_k17,e,::: le-

, l r o s i s . The epiphyseaLOSSift-44,611 c e n -

-4- -.: - ters and round bones are not S6lerotic.

,,': ,'-'• ' T h e s e sclerotic. shafts are••• , •—• ,,

- •••- _ 1 s t ro n g e r than nortriallSh44ts. -• :: „, - • ,f•,. . „ . . . . . - . . . -

. , , •::: Traumatic metaphySeal:::!•.:eilpptut. is - • , , „ ,,,_,: -, • • d u e to traumatic obstructive:;ipPrY,: to

the epiphyseal :a r t e r i o l e s i n ,-. . l h o .:: • •„ n e , t F i l -

boring cartilage plate-;., a U c t , : „. ,:q i . e . , , : : ; ' , M e - ,

taphyseal "loop7,, d e fo r,Miie e !.. . . .:0 ; * „4 u e„

' '• to stretching ', and••!ciio#onSiOn.,:;O:fi:Ahe

:: '-:•ti aumatie i n v O l i i.C . # •:: :,. t e r i n i i i . g l y , ' , . . B o th

:,..: o f these l e s i o n S:' • , g r e : , l ' : h O S t li e•M a 4 n e d

on the causa l: ' :hassi: , ' :O.f.; : thO, ',:i-;g ia-JihOg,

• . ••• , •„ , :, •,,,,,squeezing th o : ,e ] t t re n-.1 , t1 ,o S-.:: • • ' „h y, ' ,-, , • t h e ,,,a s-

,-- • sailant's hands, and „whiplash-shakingthe infant's, h e a d .; • , . . , : -. : :: : • : : :: : : • 4 : • ,( ; , :: :: ! , • • • : :: a : : ,-1 ,

Despite the fa 4 n t. .0 . ':l o t . . . , : ;P4 t0.1 * .n d

physicians to tol,apprepia,t,tho,-:-:",:k'S:ve

significande...;-:::::of.::::::. w h i p l a sh -s h a k i n g

:•.• younger infants, ' and -:!.. . t.l i e:0 4 # ::4 " ' S•fi a k -

''• :::'•--..ing:'-'-• i n - -, : in ed iC al ;-.. . h is ter iee•Op ie i!e are

• • • , - :,..,:,.• :,

,, •Brain Damage From Whiplash-Shaking of Infants/Caffc\

'V • •- •••(4-

iper-fournewRindtm a.)d is-turecan

ndi-era--;ulesthethe

;heirex-

pact

Qifle

-like2entex-

0- be

pat-,ates:ces,rous0414Y,

raüed-

44V,eu

ly

g45i

4.0theth

a#.0täJare

fey'

ef eartahl 1;5

some and,At,thp,„ same time, the most sig-i u fic an t M400,1Ofof proved pathogenic

wh i p l a S h 1 4 1.0 0 , * n f t

counted i n k t fi g ' A t n i b i f - 4 1-0 , l i i t a n t.4 n i n i e ; : l .

ported t oel , * Yoy , : ' i l l 'Od4,, t h, t 7OO, : : ,,I fi f ant s : a n d

maimed I t Vtl ier iAti i i i i i .a;;Iier ,idr lof eight.years, l a r g O V I 4 yis i • l a l p.n g 5 n n di. , j.n i t l n g ,,: p 7

I antile brains and their blood vesselsThese assaults all occurred in the homes ofu p p e r - mi d d l i 4 t 4 n S s i,. ) y e n7. ' e d t , 0 0 ; t e d . V.. 0.; t i.

do parents, who provided expert medical:care WY?: : •-h igh. ik „ ; . - t 441.: ' ' ped i ' n t . 000S, .;: : aer . : : :

services 1 4 . '.6 0 , S a r c t t 0 ',h a i C t i eO n : j.M t i p n,l I n

demand be ca u se b ui lt up a k et it 4s .

tion for being " e x t r av aga n t ly n in e to her

infant charges Both parents d o c t o r sappareiltlY:Jliakitilegnfidence in her in oneinsto.4e4d..Wkin),i,ited back by the par-ents , s e c o n d infant, a f t e rAte had shaken their first child to death_Af t , ef , ?inf ant Was found dead withouts a V d t a d t p r y:,: e a c P i a t i a t io n ; t h e n u rs e e x-

P l 4 4 4 ',A o-( sh e h ad on ly t ried to get the

bubble up " I 0004 him tin and tried toget tho!.,15.0))14,:;op,:::T.:, 441:4). do - anythingwxongyy,Ne o o * p r ,. .p f:h e rPa ti e n ts

succumbed unexpectedly, she admittedthat Sh . O .:: !.. l , nad , g iv , en : h i m: 4 g oo d s h ak i ng ,—

liecropsisliselcided'.,tranmatie'brain injury.B i e n t i t a l i y : : h•o a d Mi t t e d ' k i l l i n g t h r ee i n

f nt s and maiming two others. When theseadmissions became t o the commu-nitYPEirenta disclosed that ten additionalinfants : had been significantly injured bythin nurse

Tile primary f o rc e in all of

t I k o p.r §:0 a t ta ck s : on i nfants appears to

h4Y.:heOn':,yiolent::. whiplash shaking andeiC8diaiit.e:Whiplash;'•Pennding on the backduring burping One is amazed that she,;i„ad.!•abiS',•:to;: continue , her murderous as-

satt4l*thiS Much.better-than7aVerage so-ciat,and medical' milieu for eight years. I tis likely that she did not realize the fullpOW4r. and violence generated in her shak-i n k X;s m al l i n fa nt s. She weighed 105.32 kg

(2,33Ab), and was said to have had verylart,Onands',,Il.be last infant she shook todOft,thi:WOignftd:.:497 kg (11 lb). Had thernOkneetishanOnhy a caretaker of corre-SOncling, Weight.,.1. and :•strength, the mon-ster would haye weighed 21 times herweight or 2 , 2 2 6 kg. (5,000 113). a n dWOnIct;hayOlhaid',the st r e n g t h . o f 2 1 s : t r o n g: ,

women :'AT,44py,,2:(Fpn*CAsEs):.:LWeston6 a n dSteele and Pollock'. report: low cases of

pathOgenie:Shaking,in battered babies (1)iiilgirl2W,::Yeara old,' was shaken violently

Pis Child/Vol 1 2 4 ,,Aug 1 9 7 2 ,

Brain Damage From Whiplash-Shaking of Infaidts/Caffey 1

because she whined (2) A girl , 4 years, ofage Was Shaken violently because Of inces-sant crying : .(3) A, girl 4', months Of ,age;was,,shaken faUlly' during Which, h e r h e a d w a s •months wthi'ss, shaken 4 1 , b •( 4: s :4) , • - ;g4 .1 r 1• 1 ; , : y eof

explained 'cOnvulsioni, and

banged against, the crib , y ea r ssoltiaai beaten to death with a

31(THREE CAs -

fever • His mother Was • too shockedV9sk,A s Od ur al nPulatoma was excised

, and he died, ,three days later Eventuallythe him mother • aclinitiecl that she had shaken

several times t6 f r o p t, " c h o -ing to death" cltirine a violent Pit'roXYM' of coughing StiP h, a t t empt ed "c l e a r his61,I

throat': and he went into convulsionslowing the Shaking. (2) ', A boy, 6 monthsold, began to vomit and cnnVulSe., Therewere no external signs of head injury butretinal hemorrhages were seen in bothodder fundi. Subdural hematornas weretreated surgically:, (3) -A , f e w , d a ys • l a t e r ,

this patient's twin brother came to the hos-pital with an unexplained broken femur.Shortly thereafter, the first twin returned,with persistent subdural hematomal Bythis time bruises had appeared,on bothhis forearms, which fitted the pads' in the •fingers and thumbs,' cif': the , examiner'sbands,' where the boy's forearms hadgripped by his assailant during th e s h a k-ing, Eventually, the mother admitted thatshe and her husband "might have shakenhim when he cried, at night "' Guthkelchopines' that ,a.• "good shaking" is felt byBritish parents to be more socially accept:7able, and physically lefts dangerous, thanblows or punches to the head.

ExAmhz 4 (ONE C A s E ) .-K e m p e e t a l9

described radiographic bone lesions causedby the repeated parental shaking of a pre-maturely born twin girl of 7 months; whohad been abused by the mother since thesecond month of life. She was shaken whilegripped by the legs and held inverted. Mul-tiple massive involucra and several me-taphyseal avulsions developed In her fe-murs and tibias.

EXAMPLE 5 (ONE C A s E ), - -S w i s c h u kl' d e -

scribed compression fractures of vertebralbodies in one infant, which were believedto be due to whiplash-shaking.

EXAMPLE 6 ( T H R E E CASES) . —W e h a v e :found two examples of protective jerkingand one of repeated sibling whiplash-shak-ing. We have encountered two patients inwhom a single, sudden, violent jerk of oneextremity apparently produced metaphy-seal avulsions and traumatic involucra. (1)A boy, 41/2 months old, had always beenwell until his mother grabbed him by oneforearm and yanked him upward to pre-

,Fig 3.L.,11nexplamod •-t r a u m a t i c f r a c t u re

fragmentst ; both ends of pz0- ( n p O p f r a ctures) of the left femur with fine thin,nal thickenings of its cortex which 1:0Iiee_sent

oe al drl yr tii-aratiummaatti d ayTeit:Of:9';iiiitiedickeirA

the distal t h e two ,i;: ',Shafts;these ' lesienS;indieafe'•:that the infantr,ponths) had been 'splidd by hoth,,

vent his t d :; :t h e , , fl oO r , ; . , Of t * l a a SS i n d t .

Si*..:WOqns;latOi;:;itiftftsIv:iIti'VOluera'?,!Oine'radius and Oink iff.the: SOlidlifOiO4fn. were

d e m o n s t r a t e d : ::r a d i o g r a r :4 1 i a l l i , j * g # : l

of 3 weeks wassai d, : to have suddenly developed unexplained swell ing,O f . . A t i g ! k n e eand fever. Twelve hours latei ' i .' 4)4diatr i -eian diagnosed gs t eo r nS r e l i t i s ::: , O t ; 0 . 0§04abecause of p o i n t:, t , e n d e i.n e s s : ( : * § ; !* * e

and slight fever a n dk: l e n k O e y t o S iS i l , h 0 i e

, , . . ry.re no bru ises. TreatMent* ithl .:00'n, i0Nn

was begun. Radiographs showecUOUld,Onfracture fragments at,::th0:;.1.PlYPt,',* oneproximal tibial metapnysis w n t q l-k i n d i C a t e dtrauma l: Later films showed ; the evolutionof a longf:;tratiMati,inYnitiOtn*.Offiistibia, wh e n . , :d ie.. . . .,fe ye r' , !Wa s; s u b s i d in g O n

the 19.tki day;',.., t h e n ot h e r; : • ;. a c h n it t e c y,t 4 t ,

just prior to the.aPPearandS.Of the SWAingof the knee, she had Eg t • a h h o t t ; th O ' A a n y gn y

the leg and jerked;her M-. ) W a t t I f f t , O . :1 # 4 0 C t ,

her from falling onto a hard wood floorthe same time she had fallen,forwatd*ith, , , ,her and onto her ThdPedietricianWtaitill.reluctant to aecept:,the.:,priniary.,;.:diagnosis

of t r a u r n d . ' • b e e a u d e.: : h O , ',, l Wa S t t f t f 4 i n i l i a r

with the frequency of feYeranctileuko-cytosis af ter traumatic,. ,iiitdrnal!,:[....;:lieinor-rhage.t. (3): This boy of 8 months had had

• •••• • "• • •• • • • • • ; • • • ,••••• • "

Fig ' ,-, .,—U n ex p la i ne d large centrally

traumatic involucra on the anterolaterat as-pects o f the l ef t humerus o f a boy 1,3months of age whose parents denied trau-matic abuse. This arm had been wrapped ina bandage which bound him i n restraintduring the performance of a cerebral angip-gram, eight weeks earlier.

-

Fr i l a i n e d Massive traumatiitiyoltiOra, o f t h e l e ft h um er us of an infant 13

:months of ag e w h o se p a r en t s d en ie d t ra u-

:00tiO::gbbse The external edges of the new0 Oi t ti 6a t shell are uneven and there are large

,4,ncti,ffilall blackish patches which indicate(.056YOn resorption of blood or repeated trau-matio.opisodes with recurrent subperiosteal, ,bleeding , :, ,

unexplained swellings and tenderness andlimitation of motion in both legs for se-, rai Weeks when radiographs of the skele-ten', disclosed- traumatic involucra at the,proximal ends of both femurs. The parentsrejected the diagnosis of trauma because,other • than themselves, no one had been'4,:o4 with the infant except his 8-year-oldbrother. He, however, had frequently acted,;aka lone bahysitter when the parents wentQut socially.They found, at the first trial,

secretly watching,, t h e i r s o n a s l o ne

babyiitter; that soon after their departure

164 '•Aineri O t l . : 4 , 4 ; 1 0 g •" '" • • ••• •••• •Brain Damage From Whiplash-Shaking of Infantai6Caffey

he seized the infant l t h e legs and shookhim violently, and swung him, and flunghim onto a bed.

EXAMPLE 7 (Two CAsEs).—These cases in-volve oculovascular lesions. Gilicesl2 m e n -tions the case of Wallis in which subcluralhematorna and retinal hemorrhages re-sulted from seizing an infant by the legsand swinging him in a circle about the par-ent's head. He also refers to Breinin's in-fant patient who developed retinal lesionsafter a parent had gripped him by the tho-rax and shaken him violently:•

e

, -

aVulaidn'at;tty,e proximai and c !,-fi l e n d s o f t he b a rn e ra l ha f t

o6 boy 12 month$ (Alt The'distallhied of theshaft is thickened at'id's•ple'r fc : :•at ' . i t o a n

old, and fused t r au rna t iC' ',I n v9d luCj i i n . T h e

parents, denied, physical injury',

These 27 examples o f recordedpathogenic shak ing' represents onlyan infinites imal port ion o f the un-counted thousands of , moderate uriaci-mit ted undetected, a n d ' u n r e c or d e d

whiplash-shakings which, probablycur every day, in the United States.The actual , daily 'incidenCe,pf jpitho-genic shakings in the United States isunknown, but i t is undoUlatedly'AUb-stantial. The , admitted pathogenicwhiplash shakings b y ;ph&

-

••••••,,,t'C0••,•,••"..12.fi

'„:•„„,••••••:•:',,•,3R';•••••;',

, uirse, cited above, have a special1Ievanee because they deionstrate

ômic1uavejy that even repeated mur-' •c é l e o r years without arousing thesupicions o f educated parents and

1l-traied pediatricians, in an. opti-

oftment This long concealment was

d u1i n large part'

:to the, fact thatshakrngs, which caused fatal braindamage and intracranial bleedings:inthe xurso's patients, did not causesuggestive signs of head injury suchas -tigaPie§ P,P,,, •

ti41:4:10:Pc0' :0 ; ; ; : ; • • •o ty b u lg i ng P the

0 : 0 i , lO f O n : t a n e l . ;,. p , r): f ra e t , n re s o f t h e

• , "

and younger children 4g7:717,4ih-,41:1akinag o f i n f a n t s

re ,p e rv a s iv e , :,• : : ; P re v a len t , a n d p e r n ic i o u s'

which can be observed wher-Op r2 ;6

parents, parent-substitutes, in-fants, and small, c h i l d r e n c o n g re g a t e:

• h p irl , p rn e-, • , , p ri t h e s t r ee t , i n b us es ,

iurseries, d a y - c a r eentersOrphanages, "preschool"chogls, in parks;, playgrounds, shop-,iiepenterS;.andeyea,'n-i; t h e w a i t i n g

: : ., , !! ". .A .* :?ped ia tr ip clinics. Many well-

intentioned, responsible parents, whoinkAiothhIg,,of g i v i n g a s m al l c hi l d

7 0 0:k a ha k in g 7:: o r a series of such

sliakings, n o t dream of givingl t : § h l i ld,' , a , S P r ie s o f " g oo d " b lo ws or

. ;OphPaE-• '.0*-the head. Yet, the cumula-

Xle!:::•,:pathogenic effects o f repeatednl4k,!-.:or m od er at e wh ip la sh -s ha ki ng s

of the -t h ou g h i n ap pa r en t ctl i nai -

call a y hbe m o r e graVi:single, even i f heavy, b lows o rn n p h O S-, 1 0 ; : t h e h e ad . T he h is to ry of

trauma and the nature of the trau-used cannot usually be„ „. :

-•• ,0401,,teck:::,sometimes o w i n g t o t r a u-

na.:4,,Amnesia o f the perpetrators.'n,rnat not rpri-leMtier the traumatic

episode or the kind and amount ofviolence inflicted on the infAnt. Steelea n d ::g o l l 'o p k ,c a l l i,•-rt h i ak i n d of amnesia

or less d e f en s i v eforgetting

The grabbing and gripping of anA f a r k k,: :;:: P r , ; y3 o n n ge r c h il d„ : : by the ex-

4rern it lea:!:or,:. b y o n e l eg or arm and

•*e*::Ahalcing:hirrk seem to be instinc-

.40.:alrnO.Stirp11.4,:yiolerit actions by

- a m m v x ,

• •• • •• • ,• •: ',• -• •, -• ;• :• : ', - : -• •• •• •• •: •: •• •• •• ,. ' : ,, • ••,:,--•••";,' • ,• ••• • • • obvious•••,•••••• •:••• younger,•••••••„- • .,..•

angry adults in the commission o f i s '••• - • • • • •• ••••••• • .• •• •••• ••••. ••••,•••• ,••••••,•:•,,,•• „ , • •-iiii,i1f0V4§'saOlt•;;:0174Or.,ordiriair'• • : • • • • C a d y a r i * :,. 0 .,: a i n a l l e r,• 0 1 1 4 F 9 W ' •

-:;„•ii.A1);•,tE,•••••,,,•••6'are whipped, beaten, and ca lva ria o f the fi rs t weeksinfantsSpanked, as well as s h a k e n T h e f r e - i i o nt h s , w er e not d es ig ne d fci'r tØ

•;:'.8•1i14:ei.•6•t;;;.4:414.1•••4•••-•••••,.

versely with : '.:•••••• ••;•••••'••••••-;.'• '•-•••sh a k e n p r o t r a cte d . • ••

parently, many infants are and jerked, but few are spanked prior t h e in e vitable b r a i n - j o l t i n g o fto the seventh month of life • •

Over- adversary sports as boxing, wrearbe tling, football, and basketball wb&

vigorous pathogenic shaking mayresorted. to unwittingly, by a fright- indu lged in repeatedly fo r severT.• • t h e ••Clj''0,4 • veIji

one ••• p a re n t e

- h a za r d ou s

•••',••••,",;•!•:::••••04.4$:;•;,•

prpn

:-.PrOunsi.117117, : , d .performancest o y s a n d r e c r e a t

overvigorous "burp- "M an y : 0 • • • l l t e,: ,

, , • •• , : • • ,, : , . ,

• b e fat :• , ,e,,

coughing,whining. Even ,

al, as demo

maythe story of the halio,dcu ra t ive

,,an pr o p hyl a i

netrated, in contraptions d • which k, , •"t

ch requi,re • • 're- t, infantile

' a n•

ocular, yenhemorrhagic' brainand pneumomallastmum.

There are several apparently, i n n O-

cent, accepted, habitual , praCtices,other than intentional 'shaking andjerkirig, which whiplash the head andbrain, and which Could, l e a d , t o p e r -manent brain damage. The infantilehead is subjected to some of thesestresses during such playful practicesas repeated yigorous, "tossing, thebaby into the air"; ,"riding the horse,"in which the • infant faces the parentwhile sitting, on, his pendulant shin,which i s swung ' , ventroclorsally;"cracking the whip," or gripping theinfant by his ankles and swinginghim in a circle around the parent'shead, o r spinning h im on his ownlongitudinal axis; and "skinning thecat," in which the Younger, child issuddenly somersaulted:forward, afterbeing gripped by the wrists whichhave been inserted backward be-tween h is ; thighs: In fan ts a r idyounger children are often handledtoo roughly in play by older siblingsas well as parents, in such proceduresas "shaking or sphming him dizzy." It

,451.

ant-,lash-shakes an • jolts oould n i ,be p re , e a re rn -u 3

-4 n a ye

)genicity, and bannednurse.proCedures , whipeatedwhipl,ash-shaking and 3,of the head, are ,pOtentially,, path(); • eagenic to the brain and should be e lle ctS Over pbanned or used With, proper caution. • pathogenic; 'These - itemArtificial respiration •may induce ex- ' elude baby bouncerscessiyely, high in,tracranial and intro.-, e r s and. fo r y o u ng e r pressiireS • : - , , ,

'•e a r l y juvenile use if it'

' ,'n b4;;,,01 ,9 )7(•'• ' ',•,• ' '.•••••••••• ';:.i z e i r• •• •• •t to da ,• ,• •

tha:t

• ••••••••

, g ym na s ia ,

, •, powered rocking,

3uni" sliateboarde 'arid ;Slecl•:

s ,

, i c ; :swings, seesaws, and playsldesand eye damage a r r i n S e i n e n t .,• P a r k e t h e : : :,i i i i * O e d 4 i ;

tory training a n d p r a P t e 4:? , P O 4 0 * ' •

,,horses, trampohus,

.•:•i•••• S a i n e e t i i d i o

.i i *. c o n s i d era t io n ; s h ot i l d b e

given t o j oltmg transport-vehiclewhich carry infants and sinai! chil

-• dren--bieycleS'fi;•••• y e -hides a e

: •m o t o rc y c l e e:• • a n d ;:;,i n o t *., i , , ,

driven rapidly and habitually overrough roads The recurrent exposur1'•:•••, to t h e

.s n o w in c i h i le p r 9 ha b l Y:: .9 k e r k ,' , , , .

greateStE•liaZardi;••*.,infari.01',.,.#1,#)and.,..hearingT1* pa thOgeriic;:; i. : :b ra in&

, 3olting;•:•••,whiplash • • po ten t ia lw,, •,fovpn •

fants and younger:,•childrenr,Vhn,.:?4,.t..e .„,„„::

••••:•carried habitually':ini:speedbe,StS•07;qr•O,•::.•• rough water and in small airplane, im,•••• , rough weather•••::are'"•:.:.•inanlf0StN•dia,e

•••,'••:',•'and other,y i b r a t or i ; s t i r r in l V i n a ''.

• • • • • • , • • • • • • • • , • • • • • • , • • • , • • • • ••••••: peculiarly wh e r. 1 ,,. . .t he y are sub jec tek ,t0:: ;. !' ;: :Pi ng i,i 0On4

• . ' : ••• • • •, n c lu s ly 24 hours a day, at home jVienta

••••'i. antieniotional•diebrdereare:Sak;•to,bE

more p re va le n t i : . a re n n 4 .,: : „. 9 4 ,0 n r*1

, • high noise a n d , . a i r7,y i b r a t i o n ? : l e v e l * ,. : , , ,,, .

••••; „ is possible t h a t .:• • • t h e ;:n O i s e e , a n da l ' A

hrid-.inns'indueed by ràdio television••

, ...„ • ••••••;.••••••,"..B r a i n Damage From Whiplash Shaking of Infants/Caffey I• • •..;• • • • • • 1:- • ' • • • • • • • • • • • .• : • : • " •

• •.: :.•::1; :;i:: :. ', ', .. ,; ,', ,• •••;,! /; •] ;•.•. ,;.2•••, .,' •, .:' '.• ':• ,' •••••••• "

, ” . • •

' • •

, _

•.*' • •••••••• : • •

16 1 9 7 2

,

, F i g 7.•LLarge bilateral porencephalic cavities. Top left and top r ight, Frontai projectionsat the seventh week. Bottom left and bottom right, Lateral projections two weeks later atths i tes of needle tracks in the cerebral hemispheres of an infant who had suffered from

•,.,meningitis at 7 weeks of age and who was subjected to "needl ing" of the brain to get thea:ausal, organism for optimal treatment. -

, •,

?,•amplified hi-fi sets, air-conditionerstelephones, vacuum cleaners, blend-

and garbage disposal and dish-washing units may interfere with thehasie rest needs of the infant in hisown home when he is overexposed tothem continuously for long periods.In small thin-walled apartments, ex-cessive exposure of an infant to path-o3fgenically high-level noises is practi-cally guaranteed.

Some of the more violent forms of-„,endogenous trauma, such as the re-

Jeated. convulsions In tetanus, ep-ilepsy, o r o f meningoencephalitis-Oatised by viral infections or by lead

-,poiponing, may induce traumatic whip-lash-brain damage and mental retar-dation , The grave, frequently fatalen9ephalopathy of infantile pertussisresults, in part, from increased intra-cranial venous pressures caused by se-

,

,

vere paroxysms of coughing, which inturn leads to focal cerebral hemor-rhages and residual cerebral damage.Rhythmic whiplash habits of the in-fant himself during the first monthsof l i f e, such as head-rolling, body-rocking, and head-banging may betraumatically pathogenic to his brainand its veins. Protracted, repeated se-vere breath-holding spells ma y b esimilarly damaging to the brain.

Theoretically, the heads of infantswho suffer disorders characterized byimmaturity of their calvaria such asosteogenesis imperfecta, familial hy-perphosphatasemia, hypophosphata-sia, lacunar skull, and cleidocranialdysostosis should all be specially vul-nerable to whiplash shaking. This isalso true for the infantile disordersassociated with weakness of the cer-vical muscles.

Brain Damage

, • •

:S u d u r a j hematomasa r e 40.7,ahct

cally always traumatic In Tare found commonly- in i n f antsyounger than 24 months with a peakincidence during the sixth month' '

Th is :h ik l i t i lh e ta b il l*P '0 1 5.4 n e o n a eand i h e ' • Y o i i n e e i.: • i fi f a n t i & t r a u ma t i c

intracranial bleeding is due to thccQmbination of heavy head andw

,• „

:

,especially susceptible t o whiplashstresse4I1.6!1:.;hiC.,.t.1415,#.937 mem-branc;t1S; 0 , . a l a i I i.* ! • . ;,. * , ! 4 4 4.110 i ; a n d p e r -

mits e a y . . / $ . t r:W i I # k • : : : , b( h l i.) a l n. t r i d

• its y e i x . Wh y : : , , h . o : ',.0 : 0 • 0 , 0 * 4 y 1 fi t A i t i rec t

whiplashL..tractiOn:!...4**4044(ingand je rkin t ', : rh : : :§0 .440*.:'rop it ili i m -

mature u n i n y e l i n a t e * a.I W, ! a d d s t oi t *.;;y it Ine r a bilIty,Th.4*OWtime of

onset;.. of the subddial11740:49Ta is:usually uncertain during the firstweeks and months of lif4,40V0ost--natal trauma has long been depreeiated because it has been undetectedand ascribea::to b irth in ju ry P remature infants are very vulnerable,and the vi.fftiOabilitSi.iotfOlgt4ehl' in-fants varie'::inVeiselt*Ithagg'Nfaleinfants are twice asyiillie rah l.p i:* f e -

males; this is prObably,:,d40.it4:,,04-,itive immaturity o f ; ' : M.0 , 1-;: t i.0 . 4 4 . 4 i i i i l

brains. The hyclrocephahc, • • • • • • •1 infant is maximally:i.71.11.iietabl,e, Infantile subdural hemat0Itafre

-quently remains undiagnosed owingto the customary lack; of clI004,0:tI:i.,0

diagnostic signs and ,Syt4pt*OeIn-graham and Matson.ph;e00,.'ect:.:04)0,tory of birth in ju rylp .p .n lY2§W,44.

their 319 patients, 6 , i i . d 1,; : : i14 0.s t i : I a t a I i5 , I *.

jury in only 20%. In 5 4 7 t.h : : : ' § ' O t i 0 , 4.,

and nature of the trauma wasdetermined. Fractures o f.;:1t h e ' ; a k 4 , I

were identified in only 9 % . ;:: R O g i * t:

bruises of the scalp and face':.w4.6.1,:ii6t:sufficiently frequent to be includedtheir tables on clin ipa I lfin0 I0:0.; ',1, i4%,4

clinical picture was not characteritsii0 ; ,it was made up mainly Of.:foyt;•1:00%vulsions, vomiting;:;i:a n d h y p e r i r ri -

tability. These signs are a g , ; 0 *x:4 0 . *to many ordinary infantile dj0,0,000It is probable that p ract ica llilA lt0the small cumulative su b d i lk . a I!; h iO it *

tomas which result f romshaking remain undiagnosect';perma-:nently, and go on to OpOpme:';,ctiOr;

, • ,

From W hi pl as 1) - ,Shal s'i T l i l 9i ' : i nfA'n't$'

A3,41,64M-4:4,

Mag

,

,••i•

„, oIs . „,

, r al i a14 ?• *nd ' ,4 04,4 00;i : ,atat eth at ,,, , ;

g ) , i n i e n . t . n 1 I Y.' ; r e t a i d e d : : ,0 4 d e fi c i e n t

patients, f o r the most part, werewio suffered from large chronic,

ematomas associated with markedtrophy of the cerebral hemispheres

The ineutence o:f mental retardationn

•: 4 : ' •;: i 0 1 4 0't t , O . c ,1 ; ! 7h eT.

patients is ;did, ,, , of

the '''eniitin,i(Wrestrictedthk:nornial!,:;::

growth „ ,' • t'Afte::iAinderlying,:, cerebral, ' • • • •cortex and impaired mental growth

' i k # , 4.. e M en t i m pl i es t ha t. , t he pe r. 7, ,:

1,84nWeit, the membranes in a ll

un-de tected , , ;p at ie nt s : :

: : ' , J a r :greater number in , ,cases : of ,

U n d i ag -,

noSed, untreated chronic subduralhematoma Fo rd ' : found:::.. cerebraldamage and d e fi c i e n c y and, ,. , n , i.,0 4 i r, i ; de fi Ci t s in a large majority of

0 0.l i i1 4p ri :wh o survive after aspira-

gi.,iii;treatittent. alone. One can reason-ably conclude that whiplash-shaking,.and•:•;•Jerkini0,•,;•,:•, w h i c h : : : a r e t h e p r im e '

: 0.0.• '9.fl,,Oi .b., dt ir al,hepaa toma in di

iosed cases, a re also substantial**4:.',O:iater.:nielita,l retardation in

the countless cases of ' :,unrecognized•ihronicSiibdiiraiilipiriatorna, in far

;greater;:;40inber:Tlie'.,,frequent"r e i a l i t y h O ':: : s u b d u r a l:1 : . h e r n a to m a s a l so

i..;#A00;„!:,...,*•hiplaah•-..-1,a4:1g a s th erObablef,',eause. •••••.:„The retinal l e.§ i . . * ::c a l i § c i • b y s h ak -

:i*ilt.tindeubtedlbeeelne valuablesips in the diagnosis of subclinicalinapparent chronicaiibdural hema-tnina,:::::::::and a l so b e co r ne ;,:a l . :P r od u ct i v e

40eeriinetpst for : :.. t h e,. . . .•P r e v a l e n c e o f

* I i i i i i.a a b 4 le p e nd e n t m en ta l r et ar da -

lOn;:iiidother types of so-called idio-

su

In

damage i f f nb i l a te ra l br a in 0a0li b

b at te red 1 al- rain ge. 1 found

arotea,ux

, ,icl,'”,a'.!ssocti f o un d ' p m ts in

eenY 5

ermanenta,

*.r i ofal7 mdeotnatchhs7

P4,1e, retinal lesions In; te•,ries, of , the ocular fundifiefi e battered

hperePveioruiPshl;

battered children cl;sil'd:Ii.• ,'found retinal

associated i n t rileti.?:074 riendlyvt f

I t 's40:014dbebo.rne.io., r i:liwndi hthat t h e

-r t i a l ;,, b le e d in g s

" need li ng ".' of the brain to get: diag-

Amer C h i l d' / V o l 1 , ? A' A ug , . ,, u .„ 19 72

-

• ..,:.......:........ ;..,.• . . . . . . . . .•••P•94i.c.•;.;.

in-traventricular fluid may in itself be a. . .. dange ri at ta • .,.PrOCedureWai ld,'may lead

to extensive porencephaly •4041,1#airi, •:•destruction (Fig 7) Smith and Cro-,•• • • :••.•

.therar,f;haY.e. shown that the injectionof air into the lumbar subarachnoidspace •rnay,cause

, i n t r a cr a n i a ll . : , b l ee & : , • :: : •

: • •

tomas Overvigorous passive move-ments o f t h e in fantile head—to...,...„ „....displace the intracranial gas andplace it in optimal positions for diag-nosis—expose the bridging veins toadditional pathogenic:::stresses

Chronic in fan t ile hydrocephalushas not been reported as a residual in

" i n -fants ,cases of s u b d u r a l hetnatorria',,k1:::

mon complication of infant abuse, it••is possible t h a t residual h yd ro-cephalus has ;b e e n : p re s e r i t.b U t : i . n t is . g 0 4 '..

1.?ecaaa9••-•••it was not adequately

searched for in the currently avail-; able .inadeqiiate•studies of the late

sequels in shaken infants Cephahc.,.,•

•• h y d r o -cephalus may n o t , b e,. . ! n o t e d i i n t i L a e l ; ! ; ; ; :,•

eral weeks or months after birth,which raises the high probability thatsome, o r even much, o f the hydro-cephalus which has been attributed tobirth in jury actually, resulted fromearly postnatal whiplash-shakingThe studies of Laurie and Berne andseveral others have demonstratedthat subarachnoid hemorrhage is animportant cause of the hydrocephalusengendered by birth injury; this maybe equally true for the postnatal in-juries caused by whiplash-shaking.'

Russel' states tha t the hydro-cephalus-producing gliosis o f t h ebrain which follows hemorrhages is sosimilar microscopically to the hydro,-cephalus-producing gliosis which fol-lows infections that the two cannotbe satisfactorily differentiated. Theobstructing subependymal g liosiswhich surrounds the aqueductus ce-rebri and caues the most commontype infanof ventricular hydrocephalus intpendes m ay be e it he r i nf ec ti on -de -

nt o r hemorrhage-dependentThe same is true for the neuroglial

•

, • ••••• • . . • • ••••••••

• • • , • -4, , ••,• • „ • • • : 7 4 .- - • ,,,,,,, ,

•••••••••••••••:•.'.:::.:.••!..,,'.;'.:.•.tm.di.7.iii:e.i........:,::17...1.4.:.1•Vi...yb..:,,..,..o.di:.(ai.:;:.0i.:1...4,040:lis.c.4idpiii'....i0,:........:.'w..:!...:...;',.•:.......,....•:•.t....41i,.....::.,..t,•:.•:.....S':•:,:;,....'..6:.b.iii:,y:a.;,',....t..f.'clrg-0714!i°g':'Y:.:,4....,e:....,:...,.;111:;?;.,I3r....',.,91and

itet#il 'oT4

, •;.,„,.,!••,,,,••••,,,,„,,,;, ,••,,,,,.,.. . . .,. wh i ch • :: .1 5,1 6. e kt l i .. .9 r ,• p.. , : .. . . . ".!..,,.:'•,1

.,

...:':!i:..;•:;:.i.'l;'''.':.•:'•l'i'7:.d'•:'':o•••'•'''4:••:rt'e:ii:;Cc.'.;'I',.ii;::'f::l:•dCifi:.'ti:l..•.o'e:l:w..i.7'J...4.Ia:.1.fiC':..•.it.....:':...'.4:;....::...'ct.::.,.,•:i'.;1:;(:i:':,i.•v:'ci,.;:.:i.i..f.,„..,:t,.:..,:,..:h'',:.;.:ti..,;::.oli....i.4..,k•. 'exi,t'i::.,'I'.::.:r.fj:1:..:i:.:.t.!°•,il:•.:i:•,'il...:',•.'.".„....;:o,g.',,....,.:,

,..,..pa4I • .,::.....,....,:. ......•::1:::.4*;,••E.I.OftP,,TATil„„.,„..i;z; :i,i,,

. . . . ." ( f tb r : 9i i d,• •

•••''''g,1:11;.0 the : . : , me ..,.. ,

''',.,•,'; .. a. . .. . a; ;0 , :.:; ) ,. . .v en tr icu la r ;t 114 i.; ., ,. i.a. . r .. . .. . .. . ./,:„ '0,: i.:,' ,( : ::: :: .r. ru, .:at l: : i i. ..0P„,,7,•,••

•:::.: '•#i0.•:::.!1,'..f1:0'*.'„,'): ',. ' 9 .' ' '• :; , .: , :i ' ,'1 .,1- ' .,0 .i .;• 00 i. -4 ,0 1i t ,0 "• 4

1,..'•.'.•••••4:91;',..00.000./.„4404.y;:.,1.::,;!;...,,,...,,,. .,,,,...

, „ •. , ,,; • . ;,. .,, ,,; , : , , ,,, , ; :a,: -:, : i , ,Agoo

.

.'.,::::.''.:...:•••••••''.:...':..;l:,.'.l.1....•••••••;.''':.:...:.'•.i.;':..:..'ci:4tehrehrefhvolao:eai:

howev er , lev els .16 .64e. : :..f.I.1. i'. .°,.:6 . . . , ' ; 1 :t:: 1 . . . .' 4. :;' ' . . . f. : . : '. . ,' 1, . ' °. . lash-s hak en: : ;: .. : :1 ' . ' 4' . . . . . ' i . . ..

: t: . ...: . . . , . : a ,; . . : 1 '. i : . , . . . . :: ff ' . i a. . • . . ' : that: . : 4: . , : '. . :' common

not i '24' ' ' I : . e. ' '. I ,): . ' ' ' : 71 infant 41",.... : .4i4' . . : .' ' i . i '' 4.: . 7' -' I la' . ' , , . feature 1 .'...; P4 r' . .. ' evidence. ' - t 0, . . ' . :' ' . ' . 6' .. l '. . . ' ' . ' ' ' . . ' ': : . 'p. e; ' i '. '': ' ' '. ' . ' : . H. . ' . ' ' '' . ' ''' P . ''' ' r ..,: ' .':. t 4- A'. .. . .' '6; ' d i' . ! . :' . reported , i.. ;...'. .44 '1:°. . '.':i ;II. . °'. : i i i, .. 1whir

4:1' . ? .. f'; : : .: 7'. i''' i :

i . i.040 it ni : :: *l i ta *40 .' ,0 ., j i,i El l i' O' ,

•,

,,:::••:•:•:,,::;.'9.:h

:4g:iyifi. f:: ::: :;a. ..s:tc i.: •:. .) :e, .:popu lationsx6O1u:of. :pr' a;i, .: ,. .. :obo..11d:.c tt:u: ',6. ;::nie' f.a

. : •,. . •( sa k, . .ein i in fa ns ..,... ,....,... :

4',••••rirg,...„,,......„.......,,,,;l ,

:;,:npf

::•.;•i•::::•io.:.kiitiafi4o0,, cojtradiction

Mental retardation occurred. i nhigh incidence in two small follow-up

,••• „ • • • ••• • • • in fants,,./•••••'•••••••• ••:••••••••:,••••,•••,::,•&•

me r ' s group of 22•:••••:•':Thistelligence quotients of less than 80

incidence of 12 in 2Z become n -creased to 17 in 22 (77%), if one addsfive more retarded children who werenot available for interviews becansethey had already been admitted

:•••••,:',:state..•:...inatiOtiOnkto;ttwoi#0*01',-

:••••i,•• .• ::••••tarded No ne • ;• • • •: : • • •• • • •• • - ,• , , ' •: •: •1 ' .• , '

• . .d /TI.If: tp t h e c o nt r o l.g r oi i Rb a d,, • , si m i l, ,

ly low IQs.:::111orsefl„ef•:'41:ifOtin• ;••••;•;tJi•••.•••• i n c i d e n c e.o . fi' m e n t a l:r e t a r d a t i o nt q ! !

60% l n ' . . 1 . . § ':• • c h i l d r e.* : i i i i i n / h 4.b § i i i i • • i n

l o w e d , . . . E.O r t h r e e Ye a r a a i t ' e t•• ,:: : 0 * , : • 44, f

nal in ju ry Kempe e t a l reportedbrain damage in 25 of 45 fatal caseirt ' ".1 ,94 !::.: , • :. These • h ig lt :,. ;i nc ideneeS ti r' :.

three reports suggest that permanent

b r a i n dainage:;,and.Enienaletard4ttif': develop in a surprisingly high numbçr

• ••••-•:• , ;•• : • • • • • •• • • • • . „ • •• ,

of infants in ab u s e•has been detected Mo re detailed

•.:•,..• • ;: ••• ••• „,• • • • • • •• • •: -•:•••• •• • :• :•:.;:•••••• •'•••,••••••:.:••••••••••••:.;,.•••::;:•:•••::::.:.„'•.:••:';:•••• • •

i • •••'••;,•:' •••,„.•:1::••••••:••,'.;••••• Drain Damage:. Frein:Whipiaehlshaldi4:eftnfainglp,a, j4:0•'• • • • , • • • ..•• ••• •• •••• • • •

• • • • • • • • • • • • • • • •• • • •••• • • • • • • • • • • • • • • • • '• • • • •• • • • • • . • .• • • • • • • ..,• • • • • • .• .• • . • • •,• . f .

, •

,:••••iit•oa

akint a4• „.....,„„..of! na" :5 !1• •

firt.....„,..„rab

1W4,41,

asrela-an

:atirw l p Lictiye• 'In-3.• •, ,p :,,• •• .eoq

aIm-

-

•••-•••••••••„,„•• • „

14rerf;•„,,!••••:,•,,

.#41W4):iionalenoted in

•,•••••con',/,;,•,••imondersill ofema-etual

iron-„,...„,„,.„..

•,;•:•••••••••••,:•Yi"

araCteristic, consistent st ruc,changes , in , the brain have not •

en: demonstrated in ' so-called idio-hic juvenile Mental retardation,'iCh includes 8,0%,tO 00% Of all cases.the ease w h ip l as h -s h ak i ng , cere-

, • •raldifijuries, it is Possible that the

original, ea rlyt raumat ic cerebrale dema , the *all ,cumulative chronic

subdural hernatornas, the petechialhemorrhages, and even the larger cer-

ebral contusions have all disappearedmpletely by the time years later,•,e;:,,brains are available for autopsy.

Owingt o the frequent lack of com- •arahle degrees of structural changesin the brains of children who are se-verely mentally, it has been

suggested that the original injuries'Used irreversible change i n theenrone, themselves changes which •re not detectable microscopically orernically,,

he' cerebral lesions' of whiplash-alcen Children have not been studieddteniatically. I n some studies o fUfit• traumatic, i n j u r i es t o t he h ea d ,

e changes in the brain have d if-fered significantly in younger infants

•from those in older infants, children,and 'adults. Diffuse gliosis was com-mon in the youngest brains and may

have been the residual of earlier trau-

,Matie cerebral edema and hemor-rhage. The authors point out that

ental deficiency and motor defectsplak he due to the destruction of the, •matr ix cells , around the lateral ven-

,,,tricle.

The most striking documented clin-ical and pathologic example of mental',deficiency, induced by repeated whip-lash ,jolts to the head and which are

associated wi th profuse petechialhemorrhages in the brain, is the so-

'called punch-drunk or slap-happy vet-ran,, fi s t-fi g h t e r. He d ev el op s se-

„ere losses of memory and impair-

ments of judgment with speech andgait , disturbances from being repeat-

dly, jabbed and beaten over the headdnring, y ea r s of e xpo su re in the box-

, i g;ring; He may never suffer detect-e, acute, brain injury from a single

eavy blow; he does suffer, however,

a id, cont ro ls are needed for deternu-

lOrt,'of the true incidence.

• ....„.•:.1.0ii••Aug. 1974 ;:::•••• •

,....:,:•.,•••••••••,.,. • • ••••.: • •• :••••• • •

from the cumulative effects of,riumer-,otis, milder, repeated jabs which jolthis ibrain. I f one cared, to paraphrasethe cruel but ',realistic, lingo', of thefight game, one Could accurately de-scribe, some mentally retarded , chil-dren as "jolt-dolts”: or whiplash-silly.„, Th e exact ,prevalence of idiopathic' juvenile', mental retardation , in the

' general child population is not knownbut all r e s p o n s i b le, e s t i m a t e s i n d i c a t e

that it is woefully, high—as high as 2• •million cases in persons younger than1,8 ,years.4 .The r a t e d u r in g , i n fa n cy is

set at 0.5(io T e n percept, to I A, of children in large metropolitan Cen-

ters have been classified as Mentallysubnormal. I t is obvious that, i f thewhiplash-shaking of infants is even aruiner cause of such a pervasive anddevastating disorder, its preventionwould eliminate substantial amountsof massive human suffering and mis-ery, as well as monumental socio-economic wastage. I f one assumesthat the average family unit for eachretarded child includes two parentsand two siblings we can then appre-ciate that the lives of 8 to 10 millionadditional humans are dwarfed anddarkened by this most baneful of allchronic human scourges—juyenile,mental retardation.

Cerebral palsies and idiopathic eP7ilepsy appear to be due to postnataltrauma in many case, especially in' •those cases in which the clinical signsfirst appear weeks, months, and yearsafter birth. I t is probable that post-natal whiplash-shaking plays an im-portant causal role in some or manyof these patients. Neither of thesedisorders has yet been reported as re-sidual effects in the PITS. More, andmore comprehensive, studies a reneeded to determine the causal sig-nificance of whiplash injuries to theinfantile brain, in residual cerebralpalsies and idiopathic epilepsy*

Summary and ConclusionsShaking is generally disregarded as

a type of causal violence in the PITSby both parents and physicians and itis rarely mentioned in medical his-tories. Thus, both its frequency andpotential pathogenicity a re con -

sistently depreCiated,anCl,opr,

The ,radiograPli,i01),Oriepcbanethe PITS both t1 ie i-atribution indicate that they. areu4113, c au se d.: , 'largely by rough in

handling Of the a r m slegs, such as grabbing a n, ' tigrasping,:is4neelin0:e*inilnjerking, and then whiplash-shakof the head; , all o cc u rabsence of bruises in the skin:of

: arms and :legs. •Several ::: ' , . e Xa r n P le s 4 ;O t A :p at bo ge

je rking ;o f : the jeXtre in it i%ek*lash-shaking ' o'f:•:::,0 1 1 i O 4 C #0.k.d g : n

been r e c o r d e d., ; : i fi t h e l p y tt4ep0: ,w0.0

, W h ip l a s h-s h a k in g: i s w id el y

teed in:,alllevels by a i vvariety!ctpersons,;:jn'60M4077of ways, for a wide variety of ri

The pathogenicity of„ordifia,ual, habitual, customary, repeateshaking of infants is gerierali*Unre,,ognized by physicians",and,pge,n,

The infantile head iS:eapecialIY,',vrJo wi r ig ta combination of ;,t4e,:p•(„41./1:

ly heavy headarid,WeakneCkninSeje•, , • ,to the plasticity of an immature, par

inenibrafinuS': CalVarinin, and• • " : ,the SoftrieSs,;•,•. o f , a n: i r r i ma t i l r e ;Ain

, : :.inyeliriated,hrain..,1 orhe;:,perhaps.m a n y , o f t h e c e re

1;rovascular injuries which are currently attributed,, notk•CllniCAVmicroscopically, to prenataV4ifi ,etions, congenital ma lfo ra t io n nbirth injuries, m e t a b o l jdiseases are undptibtedlYeaOsek,,,,undetected, depreCiatediand:::,:•f,ja

parent whiplash-shak ings-:,or44 ;4first weeks and months of

In the follow-up studiessmall groups, of:, :prey ious ly, .. :;raninatized c h i l d r e n:n i e n t a l : , : r et 4 , 4 0 , 0

was found to hair,e4 surprisingly higiincidence. The mental statiisOtthedpatients was not deterri l ined..2pli0 :t ctheir traumatic abuse.

The evidence on whickOiit cOriCeptof the pathogenicity of infant4dhaing is based d o e: :. ; : i i i e-( I e n . c t ; : : : l :( a l f ,

satisfactory statisticalversa!" samples of a. t o t a l p o p u l a ti o n

of shaken infants: have notbeeif •

orn Whiplash-Shaking of Infants/Ca'

•:,10,04*(4:*haken,.!.i4nfa#t*fri*:the;

• •,:9•

1Whiplash-shakmg of the infan-

,genc to some degree I ts actual mci-eice is inknown and cannot be even

estithted satisfactorily2 Whiplash-shaking appears to be

,praetLced widely in all levels of soci-ety for many different reasons I t is

e ira l ly igiored by physicians•„

V''' 0 ,CY:Y;41.whiplash-shakings.1: : , 1 4 0 . 0 . c k ,

: . 0 kO d i: , : l i, : i g t ii . : ,; , ,z i a: ,

li•404k4f00141404:0,',174Saaini.144:::::

JOi,;•,i0ay.:::i0iiCe of ,,, •,.10446.*4"41rMili''

0 ro, I I lc1,!6:_,,,,44id

& 4 0 4 1 4 7 4 : 40fa

,T.,:c;r:4,!, ...:••;:,•,,,t,h.!:•!..re . 1 5 : i o/ ?, : , , t y , i r o f

, : • : , , : : jc than are chronic : ,P, an d

0;•.:aire

P:.k ti.:

1#0, t h e less p r obab l y m o r e

'

1411#:::,:•

4.10a i1;•*ai l i ' i l l consolCilous frequent u

P 4 h 4 E

':;;M: , X i •O i l i i . :-I4 9.se141y, i,,,....i b u t

atilt, becsahuaks e-' ,,

unrecognized

erne r a i nate mental

,0,.:;1114y,t i ,,'p e: r, c o n

s ist :

by indirect

b

..„, . 'e4,:c071,0;1:::::494urn-deceleration::e:n pd::::::aaeanisci d :E caused peminvteieoprgen t bi , i

, 1 ,, , a, ., ,._, atom

,:,,:044e si,:, d., 11e3r, , are naostw:ihnusuallytnfraries to

, q• ,. , t r a c t i o n

as , whiplash-shaking of:0,h,eotressesnol,..iatd'. s1,17Teh These : features hemiliclu include bi-

, , ,Ti l fo f , st ibdural thmas in

79, aAi0 and frequent b ilit -0,4 ;!-,e,ti,fia,l, hemorrhagei, There is a

Of ' Such signs' Of impact

iistrikingj, Ur, '.(, _;re,a ' ' lack of

as r ob l ow s

nb l o no s to the headUs u al l y t he re bruises to h

rn, sca lp , n o fractures on1P, no subperiosteal cephal-

h e 4 9, m , and f the

P1:ʻi p,• There' is considerable' manifes t•,S,riarn ,

d•:,;,mtich circumstantial evidence

ho,-„indicates t hat whiplash-shak-140,./,?Ild ,jelting,', of inf ant i le headsmay be major, unrecognized causes ofmental ' retardation and permanent::rai.,4,, dainage. The /wide practice of

yabi,tual, Whiplash-shaking for trivialreasons 'warrants, a massive nat ion- •• wide educational campaign to, alert0,Yery011O. responsible for the welfareof infants on its potential and actual•,,,,,,, •,„,, , , , . , ,pathogenicity • ,, • •, , -

a l p e rma n en t

of in-

*C tl-tw '

„ f g e

important growing other

6 . Trauma is the most killer and crippler of infants and d isIo ca t io n s. Brit J Radio-'children and i t warrants aggieS$, : t.„•••:; ••"'•••; ' ;, ,•••••: 3 . C a f f e y J :

study to insure effective preventive t h e diagnosis of traumatic injury 'w, iii4004i optimal'

s i#Iii0.V;..c li#0

soon f 1 , 4 9: 4f 5•1: '6 4 ' 4 r.P..!.::„;..Caettei•j'::IlikParent4infanttitati,u1k

: • 6.;• ped iat ri c ij;242i:;:o:As

':•. ',•:b.eacttrannia•Uamin,thelargned::::!..dr9e).(hattered: h he s vn i l r n m • : • ••-•'• • ••„ • • ••• • •••••: . . , •. , •, •: •••0

14POi. : Al,' .61. f-0, ' , : ' 4E; . ','Ke:••••,-. 0•.,. • • •

.r • • • • • • •

meal clinics; • ; : : , , , : , , , :traumatic thSpa.,seS, with the 44;70 Su0

a$Othe • • •ri,;••••••••.: :

••• •F •

•••••••b:- a l r e ady ••••• , : th .. .:1 . .f „Ch icago Press, 1965, pp 77-100.

neopasms, metabolics, • deft-ciency; and genetically determined-• • , • ,diSeases., , , • • , •• •; The problem and the prevention of• • •

whiplash injuries are ',summarizedthe following quatrain' • '

• Hark ye, flood parents, to my words trueand plain', • , , • '

When you are shaking' Your baby,' you, could be bruising his brain. '• • ' ,

So, save the limbs,, t h e b r a i n , , e v e n t h e l i fe

, • o f your tot;,, ,By shaking him never,, never and not. • ,

0 " .,):A !MENT .- : -D r, . .. • C., Henry Kempe, ',Uni-

versity of Colorado, made' available data„from his new book Helping the Battered •Child and Its Family (J. 13. Lippincott Co)̒

, In chapter 7, by Harold Martin,'42 abased' •• '' children were followed for three years Hefound 33% functionally retarded; pw; , or •these had a history of trauma- to the head;Subdural hematomas or skull' fractures '•were found in 31% and 43% had neurologic , residuals Dr. Martin points out the corn- , •plexities and interfering factors in • at,tempting to establish exactly the amount;:of permanent brain damage and mental

, retardation, which results directly, fromtraumatic abuse , • ,, A comprehensive and authoritative hiog-

• raphy of Abraham' Jacobi by J. S. Leopoldcan be found in Borden Veeder's Pediatric'Profiles, (C. V'. Moby Co, 1957). „ • ,

Drs. Bertram Girdany and Albert B. Ferguson;generously provided much excellent radiographicand clinical material from the departments ofradiology (Dr. Girdany) and orthopedic surgery(Dr. Ferguson), Children's Hospital o f Pitts-burgh,

', • • :References

thbe_

n21;.: 1 1C3c; oaaenffm' sya• ,n : fl• fractures

l ? r suffering e

r im'ca

au 3 al946. 4 - a u r n a• • • N Y ' Mu lti p l e

infants suffer Roentgen

, „ , •• •-,,' • • • ; • • • •„ „ „ „ , • , , , , , , , , , : ,,, ,,, ' ;

,rilef, :, i?ig • Child/Vol , 124; Aug 1972 • ' , • ' ' ' •• • • ' 'Brain Damage From Whiplash-Shaking' of n f :- ʻ,•, '',,';,' ,- , , ' , , • '• „ , '

• -

c h i l d r e n , study of g renareas 14hl ieVuRsEe41(i l feaMr r i' Pt ' : 40a

smal . j

( e d a . K:77,1 ' 1 , 3 •0 ; i1c1:! , ! :0 , 1 , 0,, r , d 4 ch j ,0 0 1 0 . :,41

IVersity Of ChidagQ„-ye,Sa,;;19i5i,p0

, . : • ,14 4 Ut t l eA O PS O F,

piiitcipia•; and i t S,, r e l a t i O n Sh i t ii* V h i P 1 4

I injUrlea;::;'.0rifilliedfJ•;•2t43043F19711:",

F1'iI, Steele RI

et al: The JA M:

s*ladlitik La Spine and spinal cortra*a..,:',in'the' battered chiltV:',•,SY,1•1

in Childhood JAM4 199:10,3,16,5;;;:4907! 'MJ Fundi of tlatterekha 'ie

iftinOet 2:468, 1967.„,_,,;;;:••,',;

Springfield,::::, ,111;: ;9*;k . ::.:. ,9p: i,11.4: ;04: ,, ,T '

li.§hii,;19i0,t .•.,•,:,,„„ , ,,,,;;;:,„,f.,,,,,••,, ,, :;•,.::, ,,g::•••;-„::';,,„,,,,

:;:if:•,:'14*FOrCF,R!:.Di,S•04ie'S:':; Uk•••,.'Ner;.,//'SYeteM i* 1:hfiiizc,;,01,4:,, C h i l d h o o d i i ,l i a i,v • •

•,o_ieSCey'Oe;:••• WA ',•, SpringtOk•WpiarleS

Tlooya...:,gP;.11y.lia,,,h17:er,,.,,;iiill,P060,!0'i,:,:i:i,:4;;".i'i:::Q;:'.c::c",14:k

o n c ! 7 ; . • , A,r ' w , a p t i t A, 4 / 2 . : ',7 2 3 1 , , , 3 0. , ; , : i l , q K : :: 1

:,•:.:::;.1.0.,...,Maroteaw(B: ptal.'740',furIdOf:',- -

terett babies, Pir0s4/IfitV.7571,1:,:<19.6tk.,,: :

:: :: :• ,17, :l 'r iendlki ::DS! :; :p.oi ll ie;m4'xi ito04001

of child abuse'. 'l Traii,Aiii3Ot'46aCOpt hc l

Otolaryng 75:318-332;1g1t , ' , ' , :,: :?, ::, : ; , : . , . .,;g: , :g,

18. Lorber J, Granger:It, i ; ' Ce i ••,/ ; . a k 0 a r

ities following ventriculat''puncture ; , 4 i f t , '.4- '

fants. Chi t Radiot 1498-109, 1963.:,:,::,' ,::::0:;(•: : , :19•, „,Smith I I I T , :: ' ,,; C r o th e r a "., ,, 4 ,, ,; . S . Oh d h r al ;

l • •-f hl id as a consequence Of'.; Prienniiieike '

alography. Pediat ric s ' ,5 : 3 7 5 , 3 8 0 ', . 1 9 5 0 . n ' , : • :, ,

20., Laurie 11, BertWAS:'k'ContribtitiO

on• the etiology and pathogenesis of ',0O'genital communicating„hydroCePhalksi.!Th

- ,syndrome of delaY0c1•Jimprrhagiat42::•th.

':,•:' cisterns of the transverse cerebral fissureOf,inf ants. Neuro logy i l . § : a1 : 5:43gZ1 , 065M: , : , ' ; • t e

21„ Russel DS : : : , 0.4 a 0 r i * t f , O * ; , •O i g . 4 1 • * : ! , :.: „ 2 *-,,

tlio/ogy of r e p or t::•:' series 265, Medical Research COUnCOLO

'., don, Her majesty 'a Stationery Office,gA„: Elmer E: Chitclre*/,74;::•Je'0Ordie'.•,• iStudy : of Abused MinorelancVT,heiif;170*„:,

,•:, lies'. :Pittsburgh, VniVersity::!ifl:Pitt,ShP4hp,i' PresS;;:.1967. ?1:,: ' ' : 1,: „ •: ; •••: ; : • ; : ' ,1 . : : ::•••••, : • : : ". : , - !,: •••••:,• , : ' „ ' :1; , : : ! : : : , M, , , , : :! :,c ' qr

23.; Morse Oiv.:;:, Sahler •::' (MK:: 'Friedman: SB: A three-year'stlid4og, a...boocti 0 4 *

::• glected children ;::::•• A.. ? ? ?,e r ' : . : • ; ' 4 . 1 • • • • • :! : , X 0 : 01. 4

i; 120439- 44, 1970: : ; ' ' ” :'': " • :' ' ' '." ' :',.:',::'::::' ,;' 0

•,;•• 2 4 . Christy RA::, L e n g t h e n in g S h a d*

Report of the American AcademY;;Ot:: d i atria* on the Delivery of lgei,;iial.: '!M„to Childien::,1970' p GO , ,::',:::::,' ::,•,•',":,•••••:,••:':;:',::;',•••'" ''''','

".6,re .

iges inOrdreusu-

L thenge0.4gt4410,0e#of- thé-0:i„j49;w:igve

•••••,-

4 '.:ST; ;I der

i a#6

ntsV * 4 4 J 0ingt o

iiscJe

md to

core-eur-

infec-••••,• •abolicmdbymap-g' the

twomuma-tation

;•v•!•'•

•••

..00Pt4,0

.2„,

shak-'if to

ation

affey

„Lt: