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a violent shaking or jarring of the brain and a resulting transient functional impairment Yet despite numerous postulates of physical changes within nerve cells, axons, or myelin sheaths (vibration effects, formation of intracellular vacuoles, etc), little convincing con rmation of their existence has been possible in humans or in experimental animals Similarly the word contusion, meaning a bruising of cerebral tissue without interruption of its architecture, is applied rather indiscriminately to a variety of clinical states, some of which could not depend on a pathologic change of this type, eg, minor contusion state or syndrome an expression introduced by Wilfred Trotter, who was himself critical of words that embalm a fallacious theory In all attempts to analyze the mechanisms of closed, or blunt (nonpenetrating), head injury, one fact stands pre-eminent that there must be the sudden application of a physical force of considerable magnitude to the head Unless the head is struck, the brain suffers no injury except in the rare instances of violent exionextension (whiplash) of the neck and somewhat controversial cases of crush injury to the chest or explosive injury with a sudden extreme increase of intrapulmonary pressure The factors of particular importance in brain injury are the differential mobility of the head and brain, the tethering of the upper brainstem while allowing movement of the cerebral hemispheres, and the relationship of injured parts of the brain to dural septa and bony prominences As to concussive injuries, it is useful to point out that all concussions involve a physical force that imparts motion to the stationary head or a hard surface that arrests the motion of a moving head, ie, concussion does not occur if the head is stationary This is the basis of most civilian head injuries, and they are notable in two respects: (1) they frequently induce at least a temporary loss of consciousness and (2) even though the skull is not penetrated, the brain may suffer gross damage, ie, contusion, laceration, hemorrhage, and swelling A theory that would bring into plausible form these physical and gross neuropathologic changes and their relation to transient loss of consciousness (concussion) or prolonged coma has been formulated only in relatively recent years By contrast, high-velocity missiles may penetrate the skull and cranial cavity or, rarely, the skull may be compressed between two converging forces that crush the brain without causing signi cant displacement of the head or the brain In these circumstances the patient may suffer severe and even fatal injury without immediate loss of consciousness Hemorrhage, destruction of brain tissue, and, if the patient survives for a time, meningitis or abscess are the principal pathologic changes created by injuries of these types They offer little dif culty to our understanding These various types of head injuries are illustrated in Fig 35-1 The relation of skull fracture to brain injury has been viewed in changing perspective throughout the history of this subject In the rst half of the century, fractures dominated the thinking of the medical profession, and cerebral lesions were regarded as secondary Later, it became known that the skull, though rigid, is still exible enough to yield to a blow that could injure the brain without causing fracture Therefore the presence of a fracture, although a rough measure of the force to which the brain has been exposed, is no longer considered an infallible index of the presence of ce-.

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