Calling things what they are

Abstract

We physicians pride ourselves on our adherence to the scientific method and on the objective analysis of facts to advance our field. The excellent paper by Al-Holou et al.1 in this issue reminds us that in addition to hard data and quantifiable measurements, semantic choices play a large role in how concepts spread, are challenged, and evolve. Sometimes what we call something hinders our ability to observe all the available facts clearly and come to a more correct or more encompassing understanding of a particular disease process. As Al-Holou et al. have documented, such was the case with subdural hematoma (SDH) in infancy. Because this entity was described at a time when infectious etiologies were being discovered for all kinds of conditions, SDHs too were thought by some to be inflammatory in nature. Thus the term “pachymeningitis hemorrhagica interna” was born. The widespread use of this term likely contributed to many cases of child abuse reported in the literature being ascribed to inflammatory, infectious, or metabolic causes. In addition, as the authors have detailed, Trotter’s maxim that “nothing is as antigenic as a new idea” prevented those such as Ambrose Tardieu, who observed all aspects of these cases in infants and young children and recognized them as traumatic in nature, from being able to convince others of his novel and more comprehensive insights. We are at a more focused but similar juncture at the present time. Because of the now widespread adoption of the term “shaken baby syndrome” and its application to children with every possible constellation of specific clinical and radiological findings, it is common to assume that the actual act of shaking “had to” have occurred when infants are found to have blood in the subdural space “without adequate explanation.” That violent shaking by an adult can cause the subdural hemorrhage and major neurological sequelae seen in many infants is a hypothesis that to date has eluded direct proof, although a body of indirect evidence remains supportive of this possibility in some cases. Just as assumptions that scurvy must have been present even when assays were negative, assumptions about “shaking” may blind us to understanding those cases in which infants are struck, thrown, beaten, and clearly physically abused—but not shaken. The choice of terminology also narrows our perspective so that we can miss those unusual cases in which blunt accidental trauma is the best explanation for the findings. Because of a name, we can miss those instances in which a medical condition associated with subdural hemorrhage may be present. Our prevention efforts, though well intentioned and thoughtful, can miss the mark if they are focused on a particular action instead of a potential range of violent actions. For these reasons, some organizations dealing with issues of child abuse have recommended terminology that does not narrowly define a specific mechanistic cause of a particular entity. Thus, terms such as “inflicted head injury,” “nonaccidental trauma,” and “abusive head trauma” are advocated for situations in which head injury occurring at the hands of a perpetrator is identified.2 Others have broadened the terminology used to “shaken baby syn472 473