The American History of Wartime Head Injuries and Helmets, Part 1

  

The wounds, treatments, and helmets from Bunker Hill to Kandahar

Traumatic brain injury has been declared “the signature wound” of the wars in Iraq and Afghanistan, with “nearly 350,000 incident diagnoses of TBI in the U.S. military since 2000.” A combination of better body armor and helmets, faster medical treatment, and the widespread use of improvised explosives devices (IEDs) by insurgents means that vastly more U.S. service members are surviving injuries – but suffering lasting damage to the brain caused by explosions.

Wartime head wounds of all types have been suffered, studied, and treated since the beginning of armed conflict, of course. And both medical treatments and helmets have evolved along with the weapons and conditions that cause these wounds.

The modern medical understanding of head injuries

The two basic classes of head injury are open,which is also known as a “penetrating”head injury, and closed. An open head injury happens when an object breaks through the skull. A closed injury occurs when an object strikes the head without fracturing the skull. From there, the major types of injuries get more specific:

• Hematoma is “generally defined as a collection of blood outside of blood vessels.” When a hematoma occurs in the head, it can be classified as an epidural, subdural, subgaleal, or subarachnoid hematoma, or as an othematoma or cephalohematoma.
  
  Each of these terms describes where the injury causes the blood to gather. For examples, a subdural hematoma is a mass of blood “between the brain tissue and the inside lining of the brain,” whereas an epidural hematoma is a collection of blood “between the skull and the outside lining of the brain.”
• Hemorrhage is any form of uncontrolled bleeding. Like a hematoma, this bleeding is classified by where it takes place. A subarachnoid hemorrhage refers to bleeding in the space between the brain and its lining, whereas an intracerebral hemorrhage describes bleeding within the brain itself.
• Edema refers to any form of swelling. Cerebral edema happens when a head injury causes the brain to swell, which can create life-threatening “pressure inside the skull,” also known as intracranial pressure. This pressure can also be caused by fluid, including the bleeding of an intracerebral hemorrhage.
• A skull fracture is when an object strikes the skull hard enough to break it.
• A diffuse axonal injury, also known as a sheer injury, “is an injury to the brain that doesn’t cause bleeding but does damage the brain cells.” Explosive blast waves can cause sheer injuries.
• And a concussionis a form of traumatic brain injury (TBI) “that affects … brain function.” A hard blow to the head, violent shaking, a fall, the blast of an explosion, or anything that causes the brain to impact with the skull can cause a concussion.
  
  Concussions have historically been graded as one through up to six in different diagnostic systems, depending on the symptoms they cause. For example, a Grade One concussion in the widely-used Colorado Medical Society Grading System for Concussion involves no loss of consciousness and confusion without memory loss, whereas a Grade Three is assigned when an individual lost consciousness.

There is no one standard however – and traumatic brain injuries overall are generally classified as mild, moderate, or severe.

All of these forms of head injury have been present in every conflict, though the frequencies have changed. Deaths from penetrating head injuries caused by bullets or shrapnel were more prevalent in earlier wars, for example, whereas the recent conflicts in Afghanistan and Iraq have been dominated by survivable closed head injuries.

A historically brief farewell to helmets

Helmets are of course the vital protective gear for the head, and they have a vast, ancient history in armed conflict. Sumerian soldiers wore copper helmets as early as around the 25^th Century B.C. to protect their heads from arrows, spears, swords, clubs, and other weapons. The ancient Assyrians, Persians, Greeks, and Romans all used helmets variously made of leather, iron, and bronze.

Western Europe saw its own evolution in protective gear, as helmets morphed from common leather skullcaps to heavy steel helmets during the medieval period, and finally “light, open helmets with broad brims” in the 16^th and 17^th century.

By the 17^th Century, many European armies had started shedding their heavy armor as muskets replaced swords, spears, and pikes – and firearms also caused the helmet to rapidly disappear from the battlefield by the late 17^th and early 18^th Centuries. Functional helmets were scarce when the American Revolutionary War broke out in 1775.

 

A portrait of Lieutenant-Colonel Banastre Tarleton by Sir Joshua Reynolds. A variation of his headgear, often called “the Tarleton helmet,” was worn by both British and Continental cavalry in the Revolutionary War.

The exceptions included some tough hats made of bearskin, cloth, and metal that were worn by grenadiers, embossed metal shakos worn by Hessian fusiliers, and the leather or brass headgear typically worn by cavalry. The most famous of these helmets was the Tarleton helmet, which the British associated with cavalry commander Banastre Tarleton. This “leather helmet with a sturdy tapered peak was adorned by a fur crest and dyed feather plume” and it was worn by both British and American cavalry.

Revolutionary War helmets afforded some protection, but they were mainly decorative. Hats were the norm among common soldiers.

Revolutionary medicine in a revolutionary war

John Jones, M.D., has been lauded as a “Pioneer, Patriot, and [the] Founder of American Surgery.” He received his Doctor of Medicine degree from University of Rheims in France in 1751 before moving back to the American colonies to help found King’s College Medical School, which eventually became Columbia University’s College of Physicians and Surgeons.

Jones wrote the first published medical text in US history, and his subsequent Plain Concise Practical Remarks on the Treatment of Wounds and Fractures became “the surgical manual used by military field surgeons” during the Revolutionary War. An enthusiastic patriot whose patients included George Washington and Benjamin Franklin, he outlined his motivations for writing the book in its introduction:

The present calamitous situation of this once happy country, in a peculiar manner, demands the aid and assistance of every virtuous citizen; and though few men are possessed of those superior  talents, which are requisite, to heal such mighty evils as now threaten the whole body politic with ruin and desolation; yet, every man has it in his power to contribute something towards so desirable an end; and if he cannot cure the fatal diseases of his unfortunate country, it will, at least, afford him some consolation to have poured a little balm into her bleeding wounds.

Revolutionary War wounds were caused by musket balls, cannons, and a variety of melee weapons, including bayonets, knives, clubs, hatchets, and swords.

 

 Jones discussed head injuries in three chapters of his book “entitled: Chapter VII: Of Blows On The Head; Chapter VIII: Of Injuries Arising From Concussion Or Commotion; and, Chapter IX: Of Injuries Arising From A Fracture Of The Skull.” A 2016 paper published in the Journal of Neurosurgery summarizes his advice on identifying and treating these wounds:

• Scalp injuries were defined by their cause: “incisional, puncture, contusion, or laceration.” Less severe injuries were not treated, whereas more serious wounds were sewn up with sutures, bandaged, and/or drained to relieve pressure in the head.
  
  Jones also described the treatment of complications such as “inflammation, delirium, lock jaw, or fever” with “anodynes, purgatives, antispasmodics, and bleeding.”
• Concussions were diagnosed when a patient experienced “vertigo, vomiting, restlessness, difficulty sleeping, and occasional fever.” They were treated with purgatives, anodynes, and bleeding. If the symptoms returned, the patient’s head would be shaved to look for missed impact wounds in the skull; if one was found, the surgeon was directed to use a trephine (drill) to relieve pressure.

• Fractures were classified as depressed or undepressed. The symptoms of both types mirrored those of a concussion, plus “delirium, drowsiness, seizures, aphasia, incontinence, paralysis, and bleeding from the orifices of the cranium.” Again, a drill was often used to relieve pressure.

Some of the medicine of the period was effective and treatments such as sutures, bandages, and trephination are primitive versions of methods that are still used to treat head wounds today.

Trephination, which involved using tools to drill a hole into a patient’s head, was employed “to treat epidural hematomas, subdural hematomas, and increased intracranial pressure, and was imperative for the survival of soldiers who suffered from traumatic head injury.” 

Other late 18^th century medical ideas had less merit, however. Doctors still widely believed that “the cerebral hemispheres were thought to produce animal spirits that were stored within the ventricles. This animal spirit was essential to the functioning of humans and represented the connection between the brain and body.”

In addition, bleeding was still a common treatment for a variety of conditions. Founding Father Dr. Benjamin Rush believed “tension in blood vessels was at the root of disease” and “turned to bloodletting to treat victims of Philadelphia's devastating yellow fever outbreak in 1793.” George Washington was bled of “two liters of blood” the day before he died, after he “fell ill with laryngitis.” And purgatives – essentially laxatives – were also used to flush bad substances out of patients in attempts to treat a wide range of illnesses.

To Be Continued: The American History of Wartime Head Injuries and Helmets

In the next installment of this series, we look at how medicine and munitions – but not protective gear – evolved in the Civil War, the bloodiest in American history. A combination of unchecked disease, outdated battlefield tactics, and the widespread use of rifle muskets and the Minié ball led to over 600,000 deaths in the conflict. Stay tuned.