Copyright 2005 by John F.  Murphy Jr.                                                                                                                                                                                          

                                                            "The Truth Shall Set You Free"

            Respectfully Dedicated To Patrick Meehan,  former District Attorney of Delaware County, PA,  and now Federal District Attorney for Southeastern Pennsylvania,  for his years of honored service to his community and country.

            “In the United States traumatic brain injury (TBI) is a leading cause of death for persons under age 45. TBI occurs every 15 seconds. Approximately 5 million Americans currently suffer some form of TBI disability. “  Brain  Injury.com (1)

“One picture is worth a thousand words.”  Confucius

Source: Medlineplus Medical Encyclopedia, “Shaken Baby Syndrome,” http://www.nlm.nih.gov/medlineplus/ency/imagepages/9013.htm.

            I.  HEAD INJURY AND SHAKEN BABY SYNDROME (SBS)  

            Shaken Baby Syndrome (SBS) is perhaps the most insidious  form of infant and early childhood physical abuse confronting the law enforcement and medical communities today.  It is pernicious because it can be the direct cause of  traumatic brain injury that can lead to permanent brain damage or even death.   A  "traumatic brain injury"  has been defined as "any injury of the brain and can be caused by fracture or penetration of the skull (such as in the case of a vehicle accident, fall, or gunshot wound), a disease process (neurotoxins, infections, tumors, metabolic abnormalities, etc.) or a closed head injury such as in the case of Shaken Baby Syndrome or rapid acceleration or deceleration of the head (2)."  SBS is insidious because a baby experiencing episodes of SBS may show no outward forensic sign of child abuse,  as would be the case with scaldings from hot bath water or physical injuries from a beating.   Tragically, evidence of traumatic brain injury caused by SBS may only show up during a post mortem autopsy on a baby or young child who has died as a result of  more obvious causes,  like a severe beating. This is so because the injuries from SBS  are  "closed head injuries."  A  "closed head injury" has been cited as a head injury that occurs "when the brain has been damaged without penetration of the skull by another object...Such injury often occurs without leaving obvious external signs (3)."  Closed head injury also has been described as resulting  "from blunt trauma to the head--usually from an automobile accident or  a fall--where acceleration/deceleration forces create rotation of the brain within the skull.   Although the skull may be fractured, often it is not, and results of tests such as CT Scan or MRIs may be negative (4)."  

            The results of a  closed head injury such as those suffered during as episode of SBS can even be more severe than a  "penetrating head injury"  suffered by a gun shot.    In contrast to a penetrating head injury, as caused by a gun shot,  "closed head injuries result in more widespread damage and can result in more extensive neurologic deficits.  These deficits can include partial to complete paralysis, cognitive, behavioral, and memory dysfunction, persistent vegetative state, and death (5)."

            Because of the unusual nature of Shaken Baby Syndrome,  it is sometimes difficult for members of a jury,  when an incident of SBS results in the death of the young victim, to fully grasp the nature of this syndrome.   It is  my hope that,  by drawing parallels with similar head trauma injuries that may be more familiar to the prospective members of a jury,  the nature and severity of  Shaken Baby Syndrome may be more perfectly understood.  The two areas selected for comparison are sports injuries and automobile accidents. 

II.   THE DYNAMICS OF BRAIN INJURY

            Any discussion of brain injury suffered in relation to Shaken Baby Syndrome must begin with a brief discussion of the physiology of the human brain and skull.  While forensic study has shown that the exterior of the human skull is uniformly smooth,  the skull's interior surface is somewhat rough in comparison to the exterior area.  The Neurotrama Law Nexus has this comment to make:  "the inner surface is rough and jagged and can cause significant damage in closed head injuries.  In such injuries, the head and body are abruptly stopped, causing the brain to rebound within the skull and move over these rough bony surfaces (6)."   The brain has virtually no protection against this type of injury, only being cushioned by a protective layer of cerebrospinal fluid and a thin outer membrane.

            The dynamics of such brain injury can also be understood as an anatomical application of one of the basic laws of physics:  "for every action there is an equal and opposite reaction."  Since this law is a statement that seeks to explain an aspect  of nature it is sui generis a law that, through deductive reasoning, is meant to apply to all in nature.   This law is based on an idea of  an occurring  "primary impact" and a "secondary impact."  The easiest explanation for this law comes from the military arts,  particularly artillery. When an artillery piece, or cannon, is fired,  the primary impact comes from the explosion of the gunpowder charge which propels the projectile or shell from the mouth of the cannon barrel, or  "tube."  Immediately thereafter, there occurs the  secondary impact,  "the equal and opposite reaction."   This is the recoil that results from firing the artillery piece.   Modern artillery pieces,  like the British A590 self-propelled 155 mm howitzer, have a sophisticated system that controls the force of the recoil.   However in earlier times,  for example in the American Revolution,  the recoil that followed the firing of the cannon was uncontrolled,  and the cannon itself leaped backward.   (This is the origin of the term  "a loose cannon,"  that signifies a person who is out of control.)  The gun crew would have to quickly step away from the cannon to avoid suffering serious injury or death from the recoiling cannon.

In the case of SBS, the primary impact would be considered the actual shaking of the baby or young child,  while the secondary impact would be that of the brain colliding with the rough interior  of the skull.  According to the National Shaken Baby Syndrome Campaign web site on the  Internet,  “Head trauma is the leading cause of disability among abused infants and children.

Shaken Baby Syndrome occurs most frequently in infants younger than six months old, yet can occur up to the age of three. Often there are no obvious outward signs if inside injury, particularly in the head or behind the eyes. In reality, shaking a baby, if only for a few seconds, can injure the baby for life. These injuries can include brain swelling and damage; cerebral palsy; mental retardation; developmental delays; blindness; hearing loss; paralysis and death. When a child is shaken in anger and frustration, the force is multiplied five or 10 times than it would be if the child had simply tripped and fallen (7). “

III.   CLOSED HEAD INJURY AND SPORTS     

            Closed head injury, or brain injury  is a trauma found very often in the world of sports.  According to the Brain Injury Association, the most common type of brain injury is a concussion (8).  The Centers For Disease Control And Prevention published a report on  "Sports-Related Recurrent Brain Injuries--United States,"  in its Morbidity and Mortality Weekly Review,  the MMWR, on March 14, 1997.  According to the study,    "an estimated 300,000 sports-related traumatic brain injuries (TBIs) of mild to moderate severity, most of which can be classified as concussions (ie., conditions of temporarily altered mental states as a result of head trauma),  occur in the United States each year (9)."

            Traumatic brain injuries constitute a virtual epidemic across the entire spectrum of American sports.  The American Association of Neurological Surgeons published on the Internet in  September 1999  a daunting over-view of the extent of head trauma which is related to sports.  The Association reported that  "each year, more than 750,000 Americans report injuries during recreational sports [sports that are not played professionally like hockey or boxing],  with 82,000 involving brain injuries.  In fact, brain injuries cause more deaths than any other sports injury (10)."

            There has been increased recognition among American team sports (football, hockey, and so on) about the dangers of concussion and brain trauma.  US Football.com states now   “When a player is hit, he may receive a blow to the head and become unconscious or demonstrate changes in behavior. If the player regains consciousness, seems to be alert and oriented, and is eager to play, a coach may feel the player is fully recovered and allow him back into the game or practice. However, the player has suffered a concussion. Failure to recognize a concussion can potentially lead to coma and death particularly if a second impact occurs. Coaches need to be aware of the signs of concussions and treat the situation properly (11).”   The Brain Injury Resource Foundation remarks “Traumatic brain injuries are a common occurrence in sports. Epidemiological studies suggest that over 60,000 traumatic brain injuries occur among high school athletes each year. Football, ice hockey, and soccer are associated with the highest rate of injury. The incidence of traumatic brain injury is even higher when recreational sports such as horseback riding and downhill skiing are considered .

Although athletes occasionally sustain severe brain injuries that can result in fatalities, they are much more likely to sustain milder injuries, typically referred to as concussions. The definition of concussion is still debated, but is commonly said to involve a traumatically induced alteration in mental status that may or may not involve a loss of consciousness (12).”

            Of all the sports played in America today, none have the potential for traumatic brain injury as much as boxing.   The Physician And Sports Medicine for January 2000 notes that nearly 90 per cent of professional prize fighters have sustained a brain injury during their careers (13).  This is so because it is the intent of boxing for one fighter to incapacitate his opponent, and the most effective means to do is by continually punching at his head.  This is the best  way for a boxer to win a boxing match by scoring a KO,  a  "knock out," or a TKO,  a "technical knock out" against the other boxer.   The result of such a blow is a concussion which will render the opponent unconscious, thus giving victory to the boxer who struck the "knock out" blow.   A secondary reason is to cause a cut above the opponent's eye,  because such cuts tend to bleed profusely and thus will seriously impair the opponent's ability to carry on the fight.   All such blows of course contribute continued offenses to the opponent's brain.

            Tragically, the desire to score a knock-out blow in the boxing ring can have potentially fatal consequences,  from the cataclysmic brain insult known as acute traumatic brain injury.   On April 8, 2001,  CBS SportsLine.com carried the story of the Australian boxer Ahmad Popal.  According to the SportsLine.com report,  "television footage showed Popal fall and hit the back of his head on the canvas in the sixth round.  He had taken a series of punches from opponent Tony Pappas."   Following the death of Popal,  Australian Medical Association spokesman Dr.  Chris Merry remarked that  "it is a barbarous sport where the sole purpose is to punch someone else and cause physical damage (14)."

            Because of the nature of boxing,  it is common  for a prize fighter to undergo many blows to the head during the course of his career.   This leads to the condition known as chronic traumatic brain injury (CTBI).   This is a type of traumatic brain injury that features irreversible brain damage.   In boxing,   a victim of CTBI has always been referred to as  "being punchy" or "punch drunk."  The Centers for Disease Control and Prevention commented even "repeated mild brain injuries occurring over an extended period  (ie., months or years) can result in cumulative neurologic and cognitive deficits (15)." The Physician and Sports Medicine observes, “Acute traumatic brain injury (ATBI) represents the neurologic consequence of concussive and subconcussive blows to the head. Evidence suggests that ATBI may be associated with boxing and collision sports such as American football and soccer, thus potentially exposing millions of athletes annually.

Of all sports, boxing is associated with a large number of deaths relative to the number of participants and ATBI.   Because the objective of a boxing match is to make one's opponent unable to fight, it is not surprising that ATBI occurs in boxing matches and sparring sessions. Jabs and angled blows to the head deliver acceleration-deceleration, linear, and rotatory energy vectors that may result in ATBI.

In addition to ATBI, chronic traumatic brain injury (CTBI) is of concern in boxing. CTBI from sports activity is often insidious. Onset begins with mild subclinical dysfunction detected only through neuropsychological investigation  and evolves into the slowed motor performance, tremors, cognitive deficits, and personality and psychological changes typical of chronic traumatic boxer's encephalopathy (punch drunk syndrome) . The amount and severity of ATBIs received during a boxing career appear directly related to the severity of CTBI (16)”

             It is the contention of this paper that chronic traumatic brain injury, with all its later implications,   may also occur as a result of continued episodes of Shaken Baby Syndrome.

                        Acute traumatic brain injury, resulting in death, can and does take place in football as well as in boxing.   According  to an article on CBS SportsLine.com for October 20, 1999, a San Jose, CA, high school football player   "died Tuesday, three days after injuring his head in a collision with another player and a month after sustaining a concussion in another game.  Joseph Barajas, a sophomore at Pioneer High School, collapsed on the sidelines after slamming into an opponent during a junior varsity game...Hospital officials listed his cause of death as 'traumatic brain injury  (17)."

            However,  the causation of Barajas'  fatal head injury is somewhat more sophisticated;  as will be seen the causation has a definite parallel with the thesis of this paper on Shaken Baby Syndrome.  The death of Barajas appears to be the result of what has become known as  "second impact syndrome,"  which the article on sports-related injuries in the Morbidity and Mortality Weekly Review characterizes as "repeated mild brain injuries occurring within a short period (ie., hours, days, weeks) can be catastrophic or fatal (18)."

            The Brain Injury Association notes that "football is responsible for more than 250,000 head injuries in the United States....Football players with brain injuries are six times more likely to sustain new injuries (19)."   On May 16, 2001,  the CBS SportsLine.com carried notice of a disturbing study about former players in the National Football League, the NFL.  The report was conducted in 1995-6 by the National Football League Players'  Association.   According to the findings of the report,  "more than 61 per cent of former NFL players had concussions during their playing days,  and most of them were not sidelined after their injuries."  The report mentioned that Dallas Cowboys quarterback Troy Aikman had retired in April 2001 after having sustained 10 concussions during his twelve year tenure with the Dallas team.   Repeated brain insults are thus common in football, although perhaps not as common in boxing.   The Players'  Association Report revealed that  "thirty per cent of the players had three or more concussions and 15 per cent had five or more.  Overall, 51 per cent had been knocked unconscious at least once (20)."

            Even more distressing, there seems to be in the study anecdotal evidence of   chronic traumatic brain injury among these  former players. The study also found that  “49 per cent of the former players had numbness or tingling;  28 per cent had neck or cervical spine arthritis; 31 per cent had difficulty with memory; 16 per cent were unable to dress themselves;  and 11 per cent were unable to feed themselves." Additionally, eight of the veteran players had been diagnosed with Alzheimer's Disease (21).  Commented the SportsLine.com article,  "Alzheimer's has yet to be linked directly to head injuries, though evidence suggests the two are connected  (22)."

Now, a study jointly conducted by Duke University and the National Institute on Aging has drawn a conclusion that appears to more strongly link head injury too Alzheimer's Disease.  The study also suggests that "the more severe the head injury, the greater the risk of developing AD [Alzheimer's Disease] (23)." 

            The study was done on male US Navy and Marine Corps veterans of the Second World War who had suffered head injuries, based on an examination of their war time medical records.   Dr. Brenda L. Plassman of Duke University, who helped co-author the study, said that the findings of their study were consistent with current research on the etiology, or course, of  Alzheimer's Disease [AD].  Said Plassman,  "understanding how head injury and other AD risk factors begin their destructive work early in life may ultimately lead to finding ways to interrupt the disease process early on (24)."

            Indeed, as early as 1999, The Mayo Clinic had revealed strong, suggestive links between head injuries and the onset of Alzheimer’s Disease.  Science Daily.com on the Internet reported on November 5, 1999 that “Researchers looked for evidence of the onset of Alzheimer's Disease in medical records of more than 1,280 residents of Olmsted County, Minnesota (where Mayo Clinic Rochester is located) who had suffered traumatic brain injuries between 1935 and 1984 and who were at least 40 years old at last follow-up. They compared their results with a group of 689 community members diagnosed with Alzheimer's Disease, but with no history of head trauma.

They found that the median observed time from injury to onset of Alzheimer's was 10 years in the TBI group. This was significantly less than the expected time of 18 years to onset in the non-head-injury group. Although the overall incidence of Alzheimer's among TBI cases was similar to that expected, based on rates for the Olmsted County population, the number of TBI cases with onset of Alzheimer's before age 75 was more than twice that expected. (25).”

            Perhaps definitive evidence was found in 2002.   Science Daily  News reported  that “researchers at the University of Pennsylvania School of Medicine have found direct evidence that mild repetitive head injuries can lead to Alzheimer’s disease. Their evidence suggests that brain trauma accelerates Alzheimer’s by increasing free radical damage and the formation of plaque-like deposits of Amyloid beta proteins. Perhaps just as importantly, the special breed of mice developed for the study could serve as a model in screening drugs to treat Alzheimer’s and traumatic brain injuries. Their findings are published in the January 1 issue of The Journal of Neuroscience (26).

{beta]  peptide] deposition in the brain in AD  [Alzheimer’s Disease] is strongly implicated from genetic studies. All three genes, -amyloid precursor protein, presenilin 1, and presenilin 2, now known to cause AD have been shown to cause an increase in A production or an increase in the ratio of A
₄₂/A₄₀, both of which drive aggregation (Scheuner et al., 1996B53B53; Citron et al., 1997B13B13). Possession of one or two E4 alleles of apolipoprotein E also results in increased A deposition in the brain before clinical symptoms arise (Polvikoski et al., 1995B44
B44). It is now generally accepted that deposition of diffuse deposits of Ab {Amyloid-beta]
 in the brain is an early event in the development of AD, and neurotoxicity of Ab [Amyloid beta] is well established in in vitro models (27).”

“This is the first experimental evidence linking head injuries to Alzheimer’s disease by showing how repetitive concussions can speed up the progress of the disease,” said Kunihiro Uryu, PhD, a senior research investigator at Penn’s Center for Neurodegenerative Disease Research (CNDR). “It also shows the tremendous utility of the transgenic mice and the trauma model we have developed for Alzheimer’s research (28).”

            Hockey, of course, is another sport intimately associated with head  injuries.   The New England Hockey Journal, in an article entitled “Hockey For  Your Health,” declared that “Hockey is a rough sport. According to American Sports Data, Inc., in 2002, Ice Hockey was responsible for 415,000 injuries or two percent of all sports-related injuries in the U.S. Of these, 171,000 were treated in the emergency room. A 1999 study of head injuries performed by the B.C. Injury & Prevention Unit of the Children’s Hospital in Eastern Ontario found that 18 percent of all sports-related head injuries treated in the emergency rooms occurred while playing ice hockey (29).”

With hockey, as in  any other sport, the incidence of head injury increased with the decreasing age of those who participated.   This factor was addressed by the Institute for  Preventative  Sports Medicine in July 2003. Janet Zimmerman wrote “A recent study in British Columbia found that among 440 players age 15-20, 63% of them had suffered at least one head injury, and 111 of them actually lost consciousness at some point in their career while playing minor hockey. The leading cause of concussion, whether or not the player lost consciousness, was a player’s head striking the boards, including the end glass. A $1.3 million study is underway at Simon Fraser University in British Columbia to explore concussions and mild head injuries in youth hockey players and the impact of these injuries on the lives of children and youth. The incidence of concussions in hockey is on the rise: whereas concussions accounted for 4% of reported injuries in hockey in 1996 in the U.S., the percentage increased to 17% in 2001. The actual frequency of concussions is likely to be much higher, given that these figures include only reported cases (30).”

            Indeed, head injury is a physical risk in  all sports.  In a study,  the  Faculty of Physical Education and Health of the University of  Toronto  observed, “based on the most sensitive tests for injury, and recent experience with Varsity sports, some ballpark guesses include:

·        Approximately 20 mild concussions per 1,000 athlete exposures (practices or games) the highest risk sports like football, rugby and full-contact ice hockey.

·        Approximately 5 mild concussions per 1,000 athlete exposures in moderate risk sports like basketball.

·        Approximately 1 mild concussion per 1,000 athlete exposures in lower risk sports like volleyball (31).”

IV.  CLOSED HEAD INJURY AND AUTOMOBILE ACCIDENTS

            For many other Americans, the main cause of closed head injury occurs when one is a victim of an automobile accident.   In such trauma, more victims appear to be male than to be female.  The Dr. Joseph F. Smith Medical Library reported on May 15, 2005, “each year about two million people suffer from a more serious head injury, and up to 750,000 of them are severe enough to require hospitalization. Brain injury is most likely to occur in males between ages 15 and 24, usually as a result of car and motorcycle accidents. About 70% of all accidental deaths are due to head injuries, as are most of the disabilities that occur after trauma (32).”

According to a study published on the Internet by Columbia University,  "head injuries are most common among young adult males because they have a higher rate of automobile accidents,  a leading cause of head injury.  Motor vehicle accidents cause an estimated 3 million head injuries annually  (33)."  The Neurotrauma Law Nexus remarks that "motor vehicle crashes account for 50 % of all fatal and non-fatal TBIs.  This includes all crashes involving cars, trucks, motorcycles, bicycles, and pedestrians.  The majority of fatal brain injuries are due to motor vehicle crashes (43 %) and firearms (34 %), followed by falls (9 %) (34)."  Car Accidents.net reveals that “Car accidents are a leading cause of head injuries. A brain injury can occur when the head has been struck by an object such as a windshield or the brain undergoes a sudden acceleration/deceleration movement without a direct trauma to the skull. These forces cause bruising, bleeding and twisting. Damage to the brain may occur at the time of the accident, or develop over time as tissues swell and bleed within the head (35).”   

              As the Columbia University Web page cited above notes,  "further damage can occur if an accident victim is improperly moved.  A patient with known or suspected neck injury should not be transported until the head and spinal column are immobilized and supported in a neutral position by trained emergency personnel (36)."

V.  SHAKEN BABY SYNDROME:  THE MOST VICIOUS CLOSED HEAD INJURY

            Shaken Baby Syndrome (SBS) was first identified as a medical phenomenon by Dr. John Caffrey in 1946.  A pediatric radiologist,  Caffrey  "described subdural hematomas in association with fractures of the long bones and attributed these to traumatic origins.  Subdural hematomas refer to bleeding under the dura matter, the outer membrane covering the brain and spinal cord.  The term Shaken Baby Syndrome was coined later to describe infants with subdural hematomas, subarachnoid hemorrhages (bleeding under the inner membrane covering the brain), retinal hemorrhages (bleeding at the back of the eyes), and evidence of healing fractures at the ends of the long bones.  This constellation of injuries was observed in many infants in the absence of any evidence of external injuries to the head or to the rest of the body (37)."

            The National Center on Shaken Baby Syndrome has done exemplary work in promoting realization of this serious condition afflicting not only infants but young children as well.   The Center defines Shaken Baby Syndrome as "the constellation of signs and syndromes resulting from violent shaking or shaking and impacting the head of an infant or small child.  The degree of brain damage depends on the amount  and duration of the shaking and the forces involved in impact of the head (38)."

            Based on the literature in the field, particularly that made public by the Center,  it has been possible to create a scenario on the evolution of an incident of SBS.  Characteristically, the perpetrator of an episode of SBS is a young male who has been charged with taking care of an infant or young child when the mother is not present.  (However,  women have also been the perpetrators of SBS syndrome.)   The trigger for the episode seems to be crying on the part of the child.  For the care giver, the crying becomes an impossible irritation and the reaction of the adult is rage directed at the child.   Of course, in many cases, alcohol or drug abuse are contributing factors to the anger of the adult.  As the Center notes,  "shaking occurs frequently when a frustrated care giver loses control with a inconsolable crying baby  (39)."

            Most often, it is the care giver who summons medical assistance for the injured child or infant.   Due to the criminal nature of the action, the care giver will frequently give as an excuse for the injuries a reason such as that the victim fell out of a high chair or took a fall while walking.

            It is the intent of this paper, in order better to elucidate the nature of SBS, to compare it with the other causes of closed head injury discussed herein, notably auto accidents and sports injuries.  Although clinically speaking, SBS is a unique and discrete medical and criminal phenomenon,  there are indeed parallels with these other events that may help lead to a uniform  forensic typology  that is shared by  all.

            We see in an episode of SBS the repetition of the scenario of a primary and  a secondary impact.   The primary impact is that caused by the shaking,  while the secondary can be attributed to the collision of the brain with the rough inside of the skull.   Thus, in this way, the scenario of an episode of SBS is the same as that which takes place when a prize fighter in the boxing ring delivers  a blow to the head of his opponent.  Of course, though, with SBS,  the victim is far more vulnerable to closed head injury than a mature adult boxer in good or even superior physical condition.  It is the youthful age and physical immaturity of the victim of SBS that makes he or she that much  more at risk to the trauma of the primary and secondary impact. 

            The dynamics of an episode of SBS are similar indeed to those of a closed brain injury suffered in an automotive accident.  When a baby is shaken, what happens within the skull to the brain is quite similar to that which transpires during a car crash.   The Neurotrauma Law Nexus notes that with a car accident,  "upon impact [with a fixed surface], the brain rebounds forward and backward against the skull  (this is called coup-contracoup [sic]),  which tears the subdural veins, causes damage to the temporal lobes as they move across the rough bony structures within the skull, and shearing of the blood vessels and nerve fibers" of the brain (40).

            The terms "coup" and  "contre-coup" are current within both traditional medical practice and in forensic pathology, and are of course known to those in the law enforcement and prosecution sectors as well.  According to the BBC's  The Modern Sherlock Holmes:  An Introduction To Forensic Science Today,  "if someone is struck directly on the head, say with a hammer, the brain is damaged immediately below the place where the blow fell;  this is called a 'coup' (strike) injury.  But if the victim falls and his head hits the ground, the brain injury will  be on the opposite side to the external damage.  This is a 'contre-coup' (counter-strike)  injury--the damage to the delicate brain tissue is in fact caused by the rapid deceleration of the head when it hits the ground,  not by the impact itself  (41)."

            An episode of SBS that results in the hospitalization and death of a young victim may not in fact be the first episode of SBS which that victim has endured.   Like Joseph Barajas, the young San Jose, CA,  football player who died after striking his head,  the victim who dies from an episode of SBS may be suffering the cumulative effects of perhaps several episodes of SBS suffered earlier.  These earlier episodes of SBS would have been concealed by the care giver, and no medical care would have been given to the sufferer.  As with Barajas, when the victim of SBS was taken to the hospital for the traumatic event that eventually caused death,  "second impact syndrome" was the cause.

            When a youthful victim dies as a result of a single episode of SBS,  it can likely be said that he or she has died as result of an acute traumatic brain injury, as much as a football player, boxer, or the victim of a car crash.  The shaking and impact of the brain with the hard interior surface of the  skull  in the SBS event  is sufficient to inflict such a grievous physical injury that death is the swift result.

            The dynamics of an episode of SBS are similar also to those of a closed brain injury suffered in an automotive accident.  When a baby is shaken, what happens within the skull to the brain is quite similar to that which transpires during a car crash.   The Neurotrauma Law Nexus notes that with a car accident,  "upon impact [with a fixed surface], the brain rebounds forward and backward against the skull  (this is called coup-contracoup [sic]),  which tears the subdural veins, causes damage to the temporal lobes as they move across the rough bony structures within the skull, and shearing of the blood vessels and nerve fibers" of the brain (42).

                        Chronic traumatic brain injury serves as another parallel between the trauma caused by Shaken Baby Syndrome and those injuries suffered in automotive accidents and in sports.  It was chronic traumatic brain injury that caused the former National Football League players to suffer from, in the words of the Centers for Disease Control and Prevention,  "cumulative neurologic and cognitive deficits."  An abusive head injury resulting from an episode of SBS that results in hospitalization, but not in death, can leave the victim with serious after-effects, such as "milder mental retardation, seizure disorders or developmental delays.   The spectrum of abnormalities ascribed to even milder injuries includes learning disabilities, personality changes or behavior problems.   Cerebral palsy that is of undefined origin (ie., no history of birth or intrauterine problems)  may be attributed to abusive injury, particularly shaking;  however, this relationship is difficult to demonstrate consistently (43)."

            The element that makes the trauma of SBS so sinister is that these same symptoms of brain injury may occur as the result of repeated episodes of SBS that go unreported.   Thus a child who shows such evidence of mental retardation may actually be suffering from  chronic traumatic brain injury resulting from a medical history of episodes of SBS.   Such  a child is as much a victim of  chronic traumatic brain injury as a result of exposure to repeated incidents of SBS as a prize fighter who has been boxing for years in the ring,  or a professional football player.

            An even graver threat to the victim of SBS may lurk in later years. While no such studies have apparently yet begun, using the evidence from the other types of  traumatic head injury,  deductive reasoning would point to the conclusion that, along with developmental problems and cognitive impairment when young, the victims of Shaken Baby Syndrome face a higher chance of succumbing to Alzheimer’s Disease, and at a younger age, than those who did not suffer  SBS while young.  Indeed, Mark S. Dias, MD, FAAP^*, Kim Smith, RN
, Kathy deGuehery, RN
, Paula Mazur, MD, FAAP
, Veetai Li, MD
 and Michele L. Shaffer, PhD, wrote in “Preventing Abusive Head Trauma Among Infants and Young Children: A Hospital-Based, Parent Education Program,” in the April 2005 issue of Pediatrics that “

The economic costs of abusive head injuries are significant; initial inpatient hospitalization costs average $18 000 to $70 000 per child, and average ongoing medical costs can exceed $300 000 per child..  Many children require long-term medical services, physical, occupational, speech, and educational therapies, and lifelong custodial care. Long-term management costs exceeded $1 million in 1 case (44).^”    As further studies are made (long term studies of victims of SBS are most needed), both  the economic and human costs of SBS will only mount.

                          Acute or traumatic brain injury is an unfortunate, but expected, possible outcome of a career of a professional athlete like a boxer or a football quarterback.  Acute brain injury is also a tragic outcome of an automobile accident, as this essay has demonstrated.  It is also a sad product of war.   But when acute or traumatic brain injury is the result of an episode--or repeated episodes--of SBS inflicted upon a young and helpless victim that such an injury becomes  an outrageous event.  It is for this reason that family members, relatives, medical professionals, and law enforcement personnel, police and prosecutors as well,  ought to be ever vigilant for signs of SBS events,  for Shaken Baby Syndrome is a brutal offense perpetrated against the most vulnerable and defenseless members of our society.

VI: CONCLUSION: HOPE FOR THE HELPLESS          

Fortunately, in response to this assault upon our most vulnerable Americans, efforts are now being made to decrease, or even eliminate, the preventable tragedy of  SBS.  In the same article in Pediatrics quoted above, the authors discuss a program of parental education to attack  SBS which was conducted beginning in  December 1998 in a nine county region of western  New York State served by the Women and Children's Hospital of Buffalo (WCHOB).   The authors note that “the program and its message were intentionally kept very simple, to maximize hospital compliance. Nurses were asked to have parents read a 1-page leaflet (Prevent Shaken Baby Syndrome; American Academy of Pediatrics) and view an 11-minute videotape (Portrait of Promise: Preventing Shaken Baby Syndrome; Midwest Children's Resource Center, St Paul, MN) that discussed the dangers of violent infant shaking (but not striking, slamming, or other mechanisms of abuse) and suggested ways to handle persistent infant crying. Educational posters (Never, Never, Never, Never Shake a Infant; SBS Prevention Plus, Groveport, OH) were displayed on the wards, to provide information for families and visitors. All educational materials were available in both English and Spanish (45). ^“ 

                ^{The  progrram,} which  included voluntary signed consent forms  (referred to in the article as CSs), extended into 2004.  The results were revelatory.  The authors found that “during the 6 years before the program began, 49 cases of substantiated abusive head injury were identified. This represented an average of 8.2 cases per year (range: 5–11 cases per year) and 41.5 cases per 100 000 live births (Fig 2). During the 66 months of the study period, 21 cases of substantiated abusive head injury were identified. This represented an average of 3.8 cases per year (a 53% reduction) and 22.2 cases per 100 000 live births (a 47% reduction). This 47% reduction in incidence was statistically significant (P = .0168). (46)”

Dias, who now is at the Milton S. Hershey Medical Center at Pennsylvania State University, helped Pennsylvania establish a similar program in 2002.  As Dias and his colleagues wrote in the article  in Pediatrics “The program began in May 2002 in central Pennsylvania and expanded to the eastern and western regions in 2004.” Meanwhile, as Dias notes, “ The WNY [western new york]  program has entered a second phase (as of January 2004) in which the hospital-based information is being supplemented with additional information (and another CS) provided to parents at the time of the infant's first visit with the pediatric care provider. It is hoped that a systematic approach to prevention (with appropriate authentication of results), although it will likely not completely eliminate abusive head injury, will at least reduce it to a fraction of its present level (47). ^“

These programs represent a heartening first step toward eradicating one of the most dangerous—yet most avoidable—health threats faced by our youngest and most vulnerable citizens.

AUTHOR:  John F. Murphy Jr. is Associate Professor For Intelligence Studies at The American Military University, Charles Town, WV.

 DISCLAIMER:  The opinions and conclusions in this paper are meant in no way to reflect those of the District Attorney or Office of the District Attorney of Delaware County,  PA, or the Federal District  Attorney of Southeastern Pennsylvania or of the Office.

END NOTES

This project was begun in July 2001.  It was abruptly halted by the  Attack on America on September 11, 2001, and my subsequent work on the War on  Terror.  When work was resumed upon this project in May 2005,  every effort was made to correctly attribute material to the sources used in the beginning stages of this investigative  project.

1. Brain  Injury.com, “Traumatic Brain Injury (TBI), Motor Vehicle Accident, Falls, Sports Injury,” http://www.braininjury.com/injured.html.

2.   Neurotrauma Law Nexus.  "Understanding Brain Injury."  Internet Publication, http.//www.neurolaw.com/brain.html,  p. 2.

3.  Ibid.,  p. 3.

4.  Kenneth W. Halpern,  "Neuropsychologists And Attorneys:  Collaborative Efforts In Minor Head Injury,"  Kenneth Halpern And Associates, Attorneys At Law,  Internet Publication,  p. 1.                                               

5.  "Understanding Brain Injury," p. 3.

6.   Ibid.,  p. 1.

6.  "Sports And Recreation, " Brain Injury Association,  the Internet,  p. 1.

7. Robert M. Reece, MD, and Robert H. Kirschner, MD,  "Shaken Baby Syndrome/Shaken Impact Syndrome,"  The National Center on Shaken Baby Syndrome,  Internet,  p. 1. www.dontshake.com/

8. "Sports And Recreation. " Brain Injury Association,  the Internet. http://www.biausa.org/

9. "Sports-Related Recurrent Brain Injuries--United States,"  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition, p. 1. www.cdc.gov/

11.  Brain Injury Resource Foundation, http://www.birf.info/

10.    American Association of Neurological Surgeons,  "Health Resources:  Neurosurgery On-Call,"  September 1999,  Internet, p. 1. www.aans.org/

11.   US Football.com, CONCUSSIONS IN SPORTS,

by: Michael D. Goodlett, M.D., Lawrence J. Lemak, M.D.

http://www.usafootball.com/aboutthesport/concussionsInSports.html

12.  Brain Injury  Resource  Foundation, http://www.birf.info/

 "Acute  Traumatic Brain Injury In Amateur Boxing."

13.   The Physician And Sports Medicine, Vol. 28,  No. 1.,  January 2000. http://www.physsportsmed.com "

14.   "Australian boxer dies after heavy fall,"  CBS SportsLine.com, cbs.sportsline.com/

April 8, 2001, p. 1.

15. "Sports-Related Recurrent Brain Injuries--United States."  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition. http://www.cdc.gov/

16. "Acute  Traumatic Brain Injury In Amateur Boxing."  The Physician And Sports Medicine, Vol. 28,  No. 1.,  January 2000. http://www.physsportsmed.com

17."High school football player dies from head injury."  CBS SportsLine.com,  Internet,  October 20, 1999. http://cbs.sportsline.com/

18. "Sports-Related Recurrent Brain Injuries--United States."  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition. http://www.cdc.gov

19. "Sports And Recreation. " Brain Injury Association, http://www.biausa.org/

20.  "Study concludes many former NFL players have been unconscious,"  CBS SportsLine.com,   May 16, 2001,  all material and quotations are taken from pp.  1-2. cbs.sportsline.com

21. Ibid.

22. Ibid.

23.                  “A New  Study Links Head Injury, Severity of Injury, With Alzheimer’s Disease,” National Institute on Aging, http://www.alzheimers.org/nianews/nianews35.html.

24.                  Ibid.

25. Science Daily.com, “Traumatic Brain Injury Hastens Onset Of Alzheimer's Disease,” November 5, 1999, http://www.sciencedaily.com/releases/1999/11/991105073635.htm

26. Science Daily.com. “Researchers Find Definitive Proof That Repetitive Head Injury Accelerates The Pace Of Alzheimer’s Disease,” January 17, 2002; http://www.sciencedaily.com/releases/2002/01/020117073335.htm;

27. The Journal of Neuroscience, January 1, 2002, 22(1):10-20

Rapid Tyrosine Phosphorylation of Neuronal Proteins Including Tau and Focal Adhesion Kinase in Response to Amyloid- Peptide Exposure: Involvement of Src Family Protein Kinases

Ritchie Williamson¹, Timothy Scales¹, Bruce R. Clark¹, Graham Gibb¹, C. Hugh Reynolds¹, Stuart Kellie³, Ian N. Bird³, Ian M. Varndell⁴, Paul W. Sheppard⁴, Ian Everall², and Brian H. Anderton¹ , January 1, 2002, http://www.jneurosci.org/cgi/content/full/22/1/10?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Alzheimer%27s+Disease&searchid=1116538426344_10136&stored_search=&FIRSTINDEX=0&volume=22&issue=1&journalcode=jneuro

http://www.alzheimers.org/nianews/nianews35.html

28. Science Daily.com. “Researchers Find Definitive Proof That Repetitive Head Injury Accelerates The Pace Of Alzheimer’s Disease,” January 17, 2002; http://www.sciencedaily.com/releases/2002/01/020117073335.htm;

(29).” December 14, 2004,  Dealing with Sports Injuries: Should you go to a doctor or just "walk it off"? HOCKEY FOR YOUR HEALTH,    Kevin Brochu, ://www.hockeyjournal.com/health/200412.htm

30).”
Reducing Injuries in Youth Ice Hockey:
If There’s a Will, There are Many Ways

By Janet Zimmerman, Ph.D, Institute for  Preventative  Sports Medicine, july 2003 , http://www.ipsm.org/institute_update/july_2003/summer_injuries.asp
31.  The Varsity Athlete Concussion Research Project: A University of Toronto & Toronto Rehabilitation Institute Collaboration, http://www.utoronto.ca/physical/academic/research/concussion.html

32.  Dr. Joseph F. Smith  Medical Library, report of May 15, 2005, www.chclibrary.org/micromed/00043470.html

33. "Head And Spinal Cord Trauma."  Columbia University College of P & S Complete Home Medical Guide,  Internet. http://arc.co.uk/health.arx

34. "Understanding Brain Injury." Neurotrauma Law Nexus.  Internet Publication. http://www.lawschool.cornell.edu/library/insiteasp/archive/insite184.html;  

www.neurolaw.com/.

35. “Head Injury,” Car Accidents.bet

http://www.car-accidents.net/car-accidents-injuries.html;

36. "Head And Spinal Cord Trauma."  Columbia University College of P & S Complete Home Medical Guide,  Internet. http://arc.co.uk/health.arx

37. "SBS Questions."  The National Center on Shaken Baby Syndrome,  Internet. . http://www.dontshake.com

38. "SBS Questions."  The National Center on Shaken Baby Syndrome,  Internet. . http://www.dontshake.com; Robert M. Reece, MD, and Robert H. Kirschner, MD,  "Shaken Baby Syndrome/Shaken Impact Syndrome,"  The National Center on Shaken Baby Syndrome,  Internet,  p. 1. www.dontshake.com

39. Ibid.

40. Neurotrauma Law Nexus.  "Understanding Brain Injury."  Internet Publication, http.//www.neurolaw.com/brain.html,  p. 2.

41. Williams,  Judy.  The Modern Sherlock Holmes:  An Introduction To Forensic Science Today. London:  BBC World Service, 1991

42.  Neurotrauma Law Nexus.  "Understanding Brain Injury."  Internet Publication, http.//www.neurolaw.com/brain.html,  p. 2..  London:  BBC Sports-Related Recurrent Brain Injuries--United States."  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition. http://www.cdc.gov

World Service, 1991

43. “Sports-Related Recurrent Brain Injuries--United States."  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition. http://www.cdc.gov

44. Preventing Abusive Head Trauma Among Infants and Young Children: A Hospital-Based, Parent Education Program, Mark S. Dias, MD, FAAP^*, Kim Smith, RN, Kathy deGuehery, RN, Paula Mazur, MD, FAAP, Veetai Li, MD and Michele L. Shaffer, PhD^|| ,  Pediatrics, April 2005, http://pediatrics.aappublications.org/cgi/content/full/115/4/e470?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Dias%2C+Mark+S.&fulltext=Shaken+Baby+Syndrome&searchid=1116483770578_26699&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=pediatrics;

45.    Ibid.

46.    Ibid

47.    Ibid.

BIBLIOGRAPHY

"Acute  Traumatic Brain Injury In Amateur Boxing."  The Physician And Sports Medicine, Vol. 28,  No. 1.,  January 2000. http://www.physsportsmed.com

"Australian boxer dies after heavy fall."   CBS SportsLine.com,  Internet publication,  April 8, 2001, p. 1. http://cbs.sportsline.com/

Brain  Injury.com, “Traumatic Brain Injury (TBI), Motor Vehicle Accident, Falls, Sports Injury,” http://www.braininjury.com/injured.html.

, “Head Injury,” Car Accidents.bet

http://www.car-accidents.net/car-accidents-injuries.html;

,  Dealing with Sports Injuries: Should you go to a doctor or just "walk it off"? HOCKEY FOR YOUR HEALTH,    Kevin Brochu, ://www.hockeyjournal.com/health/200412.htm

Halpern,   Kenneth W.  "Neuropsychologists And Attorneys:  Collaborative Efforts In Minor Head Injury,"  Kenneth Halpern And Associates, Attorneys At Law,  Internet Publication,  p. 1.                                               

"Head And Spinal Cord Trauma."  Columbia University College of P & S Complete Home Medical Guide,  Internet. http://arc.co.uk/health.arx

“Head Injury,” Car Accidents.bet

http://www.car-accidents.net/car-accidents-injuries.html;

"Health Resources:  Neurosurgery On-Call,"  American Association of Neurological Surgeons,  September 1999,  Internet. http://www.aans.org/

"High school football player dies from head injury."  CBS SportsLine.com,  Internet,  October 20, 1999. http://cbs.sportsline.com/

“A New  Study Links Head Injury, Severity of Injury, With Alzheimer’s Disease,” National Institute on Aging, http://www.alzheimers.org/nianews/nianews35.html.

Preventing Abusive Head Trauma Among Infants and Young Children: A Hospital-Based, Parent Education Program, Mark S. Dias, MD, FAAP^*, Kim Smith, RN, Kathy deGuehery, RN, Paula Mazur, MD, FAAP, Veetai Li, MD and Michele L. Shaffer, PhD^|| ,  Pediatrics, April 2005, http://pediatrics.aappublications.org/cgi/content/full/115/4/e470?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&author1=Dias%2C+Mark+S.&fulltext=Shaken+Baby+Syndrome&searchid=1116483770578_26699&stored_search=&FIRSTINDEX=0&sortspec=relevance&journalcode=pediatrics;

Rapid Tyrosine Phosphorylation of Neuronal Proteins Including Tau and Focal Adhesion Kinase in Response to Amyloid- Peptide Exposure: Involvement of Src Family Protein Kinases

Ritchie Williamson¹, Timothy Scales¹, Bruce R. Clark¹, Graham Gibb¹, C. Hugh Reynolds¹, Stuart Kellie³, Ian N. Bird³, Ian M. Varndell⁴, Paul W. Sheppard⁴, Ian Everall², and Brian H. Anderton¹ , January 1, 2002, The Journal of Neuroscience, January 1, 2002, 22(1):10-20

http://www.jneurosci.org/cgi/content/full/22/1/10?maxtoshow=&HITS=10&hits=10&RESULTFORMAT=&fulltext=Alzheimer%27s+Disease&searchid=1116538426344_10136&stored_search=&FIRSTINDEX=0&volume=22&issue=1&journalcode=jneuro

http://www.alzheimers.org/nianews/nianews35.html

 Reece, Robert M.,  MD, and Robert H. Kirschner, MD.  "Shaken Baby Syndrome/Shaken Impact Syndrome."  The National Center on Shaken Baby Syndrome,  Internet. http://www.dontshake.com/

Reducing Injuries in Youth Ice Hockey:
If There’s a Will, There are Many Ways

By Janet Zimmerman, Ph.D, Institute for  Preventative  Sports Medicine, july 2003 , http://www.ipsm.org/institute_update/july_2003/summer_injuries.asp

 “Researchers Find Definitive Proof That Repetitive Head Injury Accelerates The Pace Of Alzheimer’s Disease,” January 17, 2002; Science Daily.com http://www.sciencedaily.com/releases/2002/01/020117073335.htm;

"SBS Questions."  The National Center on Shaken Baby Syndrome,  Internet. . http://www.dontshake.com

Dr. Joseph F. Smith  Medical Library, report of May 15, 2005, www.chclibrary.org/micromed/00043470.html

"Sports And Recreation. " Brain Injury Association,  the Internet. http://www.biausa.org/

"Sports-Related Recurrent Brain Injuries--United States."  Centers For Disease Control And Prevention,  Morbidity And Mortality Weekly Review (MWWR),  March 14, 1997,  Internet edition. http://www.cdc.gov/

"Study concludes many former NFL players have been unconscious."  CBS SportsLine.com, Internet,   May 16, 2000. . http://cbs.sportsline.com

"Study Links Serious Head Injuries To Alzheimer's Disease."  Doctor's Guide.com,  Internet,  October 23, 2000. http://www.docguide.com/

“Traumatic Brain Injury Hastens Onset Of Alzheimer's Disease,” November 5, 1999, Science Daily.com, http://www.sciencedaily.com/releases/1999/11/991105073635.htm

 "Understanding Brain Injury." Neurotrauma Law Nexus.  Internet Publication. http://www.lawschool.cornell.edu/library/insiteasp/archive/insite184.html;  

www.neurolaw.com/.

The Varsity Athlete Concussion Research Project: A University of Toronto & Toronto Rehabilitation Institute Collaboration, http://www.utoronto.ca/physical/academic/research/concussion.html

Williams,  Judy.  The Modern Sherlock Holmes:  An Introduction To Forensic Science Today.  London:  BBC World Service, 1991.