necessary to more precisely define the learning-disabled group in order to strengthen the validity of our findings. Using the stringent criteria outlined in the article, the incidence of learning-disabled children in our districts is estimated at 7% to 8%. Further points allude to nonhyperkinetic children with short attention spans. We would concur that such children should be referred for medical examination (and consideration for medication, whether soft signs are
present
or
absent).
We will be interested to learn the outcome of the Lerers' study, suggesting a correlation between the presence of soft signs and response to stimulant drugs. RICHARD M. ADAMS, MD ROBERT E. ESTES, PHD Department of Pediatrics Southwestern Medical School Dallas, TX 75235
Delayed Onset
of Acute Post-traumatic Subdural Effusion
Sir.\p=m-\Thepurpose of this letter is to physical abuse was the actual cause behind the subdural hematomas in several of the six cases reported by Gutierrez and Raimondi in the September issue of the Journal (128:327, 1974). The authors attempt to attribute the subdural hematomas to head trauma that occurred 16 to 28 days previously; subdural taps done at the time of the acute injury were negative (five of six cases). The intervening mechanism is not discussed and is apparently mysterious. A mechanism that is well documented and could readily explain the later subdural hematomas is a violent shaking injury.1-3 This inflicted injury leads to tearing of bridging veins with subsequent development of bilateral subdural hematomas. There are no associated scalp swellings, scalp bruises, or skull fractures. More than one half of inflicted subdural hematomas are of this type.1 The authors fail to mention this entity. Other findings that support child abuse as a strong possibility in sev¬ eral of the reported cases are the fol¬ lowing. (1) Five of the six children were less than 1 year of age. More than 50% of physical abuse occurs in this age group, along with perhaps 90% of inflicted subdural hematomas. Although the patient in case 3 is listed as 4 years old, the presence of a full fontanel makes this unlikely. (2)
suggest that
The histories offered for the injuries are suspicious. In all cases, no recent explanation was offered for the sub¬ dural hematomas, a common finding in child abuse. No explanation was of¬ fered for the prior head injuries in two cases, and a "fall from a bed" was the excuse offered in four. These his¬ tories are discrepant with the degree of injury; numerous children fall from beds without acquiring even a bruise. (3) The fact that unusual head in¬ juries were repeated is suspicious. (4) In case 2, the parents were hospital shopping, a common mechanism for avoiding detection. (5) In case 4, the parents refused medical advice, namely, a shunt. (6) Only two of the six cases had long-bone surveys for inflicted bony injury. Although the authors state that there was no evidence of subsequent injuries on a one- to five-year followup, one can only wish for some elabo¬ ration on this point. Were the state central registry and the hospital's special registry checked?4 Was the child protective agency contacted? Were there any reports of abuse past or present in other members of these families? Were there any mysterious deaths in siblings? Was either parent known to have violent behavior? How many contacts were made? Did any of the patients become lost to follow-up? "Spontaneous subdural hematoma" is no longer an acceptable diagnosis. In the past, this label was a way to avoid considering the diagnosis of nonaccidental trauma. The entity re¬ ported in this article has similar po¬ tential for being used as a cover-up for foul play. The authors report a mysterious occurrence; they do not propose a mechanism. A known mech¬ anism for the same finding is violent shaking.13 If by chance this mecha¬ nism does not pertain, one could at least explore the possibility that these subdural hematomas represent an iatrogenic phenomenon occurring secondary to the original "negative" subdural taps. Down with "mys¬
terious events." Subdural hematomas are the most common cause of death in child abuse. BARTON SCHMITT, MD Pediatric Consultant, Child Protection Team University of Colorado Medical Center 4200 E Ninth Ave Denver, CO 80220 1. Guthkelch AN: Infantile subdural haematoma and its relationship to whip-
lash injuries. Br Med J 2:430-431, 1971. 2. Caffey J: On the theory and practice of shaking infants: Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 124:161-169, 1972. 3. Caffey J: The whiplash shaken infant syndrome: Manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 54:396-403,1974. 4. A Descriptive Study of Nine Health\x=req-\ Based Programs in Child Abuse and Neglect, Committee on Infant and Preschool Child. Evanston, Ill, American Academy of Pediatrics, 1974.
Reply Sir.\p=m-\Dr. Schmitt's suggestion "that physical abuse was the actual cause behind the subdural hematomas in several of the six cases reported" by us is speculative. We looked carefully for evidence of abuse in each of these children, since the battered child syndrome and shaking injuries are well known to us. Dr. Schmitt's suggestion that the intervening mechanism "is apparently mysterious" is also speculative. We clearly stated that the mechanism is unknown to us and refused the temptation to offer an explanation for which we had no objective evidence. It does appear, however, from the substance of his letter that he has information concerning the definite mechanism for the production of subdural hematomas, since he states that "'spontaneous subdural hematoma' is no longer an acceptable diagnosis." If so, that information should be published. The patient in case 3 was not 4 years old but 4 weeks old (this was a printing error). It is not clear what Dr. Schmitt means in his statement regarding "the fact that unusual head
injuries were repeated is suspicious." clearly stated that they were not repeated injuries. In case 2, the par¬ ents were not hospital shopping. They brought their child to the Cook County Hospital the first time, and then the child was brought to the nearest hospital the second time be¬ cause she was having seizures. Ac¬ tually, I was the attending physician in both hospitals on both occasions. In case 4, the family refused the shunt procedure (subdural peritoneal) after we explained to them that we had no way of knowing whether it would make the child better, and that some children with subdural peritoneal shunts developed both peritonitis and We
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present
or
absent).
We will be interested to learn the outcome of the Lerers' study, suggesting a correlation between the presence of soft signs and response to stimulant drugs. RICHARD M. ADAMS, MD ROBERT E. ESTES, PHD Department of Pediatrics Southwestern Medical School Dallas, TX 75235
Delayed Onset
of Acute Post-traumatic Subdural Effusion
Sir.\p=m-\Thepurpose of this letter is to physical abuse was the actual cause behind the subdural hematomas in several of the six cases reported by Gutierrez and Raimondi in the September issue of the Journal (128:327, 1974). The authors attempt to attribute the subdural hematomas to head trauma that occurred 16 to 28 days previously; subdural taps done at the time of the acute injury were negative (five of six cases). The intervening mechanism is not discussed and is apparently mysterious. A mechanism that is well documented and could readily explain the later subdural hematomas is a violent shaking injury.1-3 This inflicted injury leads to tearing of bridging veins with subsequent development of bilateral subdural hematomas. There are no associated scalp swellings, scalp bruises, or skull fractures. More than one half of inflicted subdural hematomas are of this type.1 The authors fail to mention this entity. Other findings that support child abuse as a strong possibility in sev¬ eral of the reported cases are the fol¬ lowing. (1) Five of the six children were less than 1 year of age. More than 50% of physical abuse occurs in this age group, along with perhaps 90% of inflicted subdural hematomas. Although the patient in case 3 is listed as 4 years old, the presence of a full fontanel makes this unlikely. (2)
suggest that
The histories offered for the injuries are suspicious. In all cases, no recent explanation was offered for the sub¬ dural hematomas, a common finding in child abuse. No explanation was of¬ fered for the prior head injuries in two cases, and a "fall from a bed" was the excuse offered in four. These his¬ tories are discrepant with the degree of injury; numerous children fall from beds without acquiring even a bruise. (3) The fact that unusual head in¬ juries were repeated is suspicious. (4) In case 2, the parents were hospital shopping, a common mechanism for avoiding detection. (5) In case 4, the parents refused medical advice, namely, a shunt. (6) Only two of the six cases had long-bone surveys for inflicted bony injury. Although the authors state that there was no evidence of subsequent injuries on a one- to five-year followup, one can only wish for some elabo¬ ration on this point. Were the state central registry and the hospital's special registry checked?4 Was the child protective agency contacted? Were there any reports of abuse past or present in other members of these families? Were there any mysterious deaths in siblings? Was either parent known to have violent behavior? How many contacts were made? Did any of the patients become lost to follow-up? "Spontaneous subdural hematoma" is no longer an acceptable diagnosis. In the past, this label was a way to avoid considering the diagnosis of nonaccidental trauma. The entity re¬ ported in this article has similar po¬ tential for being used as a cover-up for foul play. The authors report a mysterious occurrence; they do not propose a mechanism. A known mech¬ anism for the same finding is violent shaking.13 If by chance this mecha¬ nism does not pertain, one could at least explore the possibility that these subdural hematomas represent an iatrogenic phenomenon occurring secondary to the original "negative" subdural taps. Down with "mys¬
terious events." Subdural hematomas are the most common cause of death in child abuse. BARTON SCHMITT, MD Pediatric Consultant, Child Protection Team University of Colorado Medical Center 4200 E Ninth Ave Denver, CO 80220 1. Guthkelch AN: Infantile subdural haematoma and its relationship to whip-
lash injuries. Br Med J 2:430-431, 1971. 2. Caffey J: On the theory and practice of shaking infants: Its potential residual effects of permanent brain damage and mental retardation. Am J Dis Child 124:161-169, 1972. 3. Caffey J: The whiplash shaken infant syndrome: Manual shaking by the extremities with whiplash-induced intracranial and intraocular bleedings, linked with residual permanent brain damage and mental retardation. Pediatrics 54:396-403,1974. 4. A Descriptive Study of Nine Health\x=req-\ Based Programs in Child Abuse and Neglect, Committee on Infant and Preschool Child. Evanston, Ill, American Academy of Pediatrics, 1974.
Reply Sir.\p=m-\Dr. Schmitt's suggestion "that physical abuse was the actual cause behind the subdural hematomas in several of the six cases reported" by us is speculative. We looked carefully for evidence of abuse in each of these children, since the battered child syndrome and shaking injuries are well known to us. Dr. Schmitt's suggestion that the intervening mechanism "is apparently mysterious" is also speculative. We clearly stated that the mechanism is unknown to us and refused the temptation to offer an explanation for which we had no objective evidence. It does appear, however, from the substance of his letter that he has information concerning the definite mechanism for the production of subdural hematomas, since he states that "'spontaneous subdural hematoma' is no longer an acceptable diagnosis." If so, that information should be published. The patient in case 3 was not 4 years old but 4 weeks old (this was a printing error). It is not clear what Dr. Schmitt means in his statement regarding "the fact that unusual head
injuries were repeated is suspicious." clearly stated that they were not repeated injuries. In case 2, the par¬ ents were not hospital shopping. They brought their child to the Cook County Hospital the first time, and then the child was brought to the nearest hospital the second time be¬ cause she was having seizures. Ac¬ tually, I was the attending physician in both hospitals on both occasions. In case 4, the family refused the shunt procedure (subdural peritoneal) after we explained to them that we had no way of knowing whether it would make the child better, and that some children with subdural peritoneal shunts developed both peritonitis and We
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