The American History of Wartime Head Injuries and Helmets, Part 3

The American History of Wartime Head Injuries and Helmets, Part 3

August 17, 2018

“American Marines in Belleau Wood (1918)” by George Scott, Originally Published in the French Magazine “Illustrations.” Source:


The dawn of modern warfare and the return of the combat helmet

Much like the Civil War, World War I was a conflict in which tactics did not keep pace with technology. The Great War introduced the wide deployment of the flame thrower, grenades, chemical weapons, the tank, and, most significantly, the machine gun and massive use of devastating artillery.

Machine guns like the German MG 08 could shoot 500 rounds a minute and mow down advancing infantry, and were particularly effective in the trench warfare of the Western Front. Advancing troops also used machine guns to create barrage fire, which “allowed troops to fire over the heads of their own soldiers” as they advanced.

US Soldiers Throwing Grenades World War I

American soldiers throwing hand grenades toward Austrian trenches during World War I, September 1918. Source: Sgt. A. Marcioni/U.S. Department of Defense via

But it was the immense artillery barrages from big guns and mortar-style howitzers that defined the wounds and particularly the head injuries suffered in the conflict. Roughly 1.5 billion shells were fired on the Western Front, and French demining teams were still annually recovering 50,000 to 75,000 tons of unexploded ordinance in 2007.

These artillery pieces typically fired high explosive or shrapnel rounds, the latter of which had timed fuses that allowed them to explode above the heads of infantry. As a result, “[t]he multitude of head injuries associated with trench warfare in WWI challenged early neurosurgeons unlike any prior civil-military conflict.” About 60 percent of those killed in the conflict may have died of shrapnel.

And the helmet – which had been mostly absent during America’s military history – made a comeback.

The M1917 doughboy helmet

Variously called the shrapnel helmet, the dishpan hat, the tin pan hat, the Tommy helmet, and the washbasin, the U.S. M1917 was actually a version of the British Mark I helmet that was introduced in 1915, the second year of the conflict.

Like most militaries at the start of the war, the U.S. had no standard-issue helmets and quickly adopted the British equipment, which became widely-available to US troops by the end of November 1917.

The M1917 was a shallow manganese steel dome with a leather chin strap and cotton lining. It weighed about two pounds and could “protect against a shrapnel ball travelling at 750 ft/sec” but left the face and the sides and back of the head exposed. The helmet “offered virtually no protection from direct-fire weapons and objects striking the wearer from anywhere but above.”

This design “left troops wide open to facial and cranial injury, and lasting disfigurement from shell fragmentation was an enormous problem in World War I.” In contrast, the German Stahlhelm (“steel helmet”) afforded greater protection for the back and sides of the head.

US vs. German helmets WWI

American soldiers wearing M1917 helmets (left) and Austro-Hungarian soldiers wearing Stahlhelms. Sources: WikiCommons

In addition, the M1917’s chinstrap was extremely difficult to release, which caused some troops to get stuck in their helmet. Nevertheless, the M1917 and its future replacements were here to stay – along with the explosions, shrapnel, and other elements of industrial warfare, plus the head injuries caused by them.

Head injury diagnosis and treatment in the Great War

American neurosurgeon Dr. Harvey Cushing was a pioneer of brain surgery and the physician who first described Cushing’s disease, which is “an excess of the steroid hormone cortisol in the blood level caused by a pituitary tumor secreting adrenocorticotropic hormone (ACTH).”

After being commissioned as a major in the U.S. Army Medical Corps, he rose to the rank of colonel and served as “director of the U.S. base hospital attached to the British Expeditionary Force in France,” “the head of a surgical unit in a French military hospital outside of Paris,” and a “senior consultant in neurological surgery for the American Expeditionary Forces in Europe.”

In addition to helping develop a novel surgical magnet that was used to pull shrapnel from the brain, he documented his wartime experience and cases in numerous books and journal articles. Cushing classified the variety of penetrating head injuries in a 1918 article published in the British Journal of Surgery titled “A series of wounds involving the brain and its enveloping structures:”

Cushing is regarded as having been a highly effective and influential surgeon, and he “demonstrated improved results” while treating head wounds via:

  • “[E]arly, definitive operation;”

  • “debridement [removal] of devitalized brain tissue, in-driven bone fragments, and foreign bodies;”

  • “dural closure;” [The dura is a thick membrane of connective tissue that surrounds the brain.]

  • “and primary 2-layer closure of the scalp.”

In particular, quickly operating on head wounds was crucial, as the “postoperative mortality rate in penetrating injuries not receiving adequate early surgical treatment was approximately 50%, and many died before they could be treated.”

Cushing’s emphasis on early, aggressive treatment wound up having a huge influence on treating head injuries in subsequent wars, as well as the speedy nature of all medical care provided to front line soldiers.

In addition to dealing with a wide variety of penetrating head wounds, physicians grappled with closed injuries, including a new and confusing epidemic: How some mysterious combination of explosions and stress caused what are now known as traumatic brain injury (TBI) and post-traumatic stress disorder (PTSD). Initially “described during World War I by British physicians in field hospitals … The physical and psychological conditions they observed in survivors of blasts came to be known as ‘shell shock.’”

Soldiers rocked by close explosions and afflicted with this new condition displayed “a variety of physiological and neuropsychiatric symptoms,” including “cognitive and memory impairment, lability of mood and other mood disorders, and attention and/or hyperactivity disorders.”

But only about “50% to 60% of soldiers with shell shock” who were admitted to one hospital said they had been concussed, according to Lt. Col. John Rhein, a neuropsychiatry consultant to the American Expeditionary Force. Physicians struggled to define the condition and explain its symptoms when a soldier had not weathered an explosion or suffered a noticeable head injury:

Increasing numbers of soldiers who had been close to a detonation without receiving a head wound presented at casualty clearing stations with puzzling symptoms. They suffered from amnesia, poor concentration, headache, tinnitus, hypersensitivity to noise, dizziness, and tremor but did not recover with hospital treatment. Diagnosis became problematic because their clinical presentation was similar in many respects to that of soldiers who had experienced cerebral injury. The term “shell shock” evolved in an attempt to describe cases that arose in the context of exploding ordnance but where enduring symptoms could not be linked to the presence of an obvious [physical wound]. …

[R]esearch conducted in 1915 and 1916 by Myers, consultant psychologist to the British Expeditionary Force, led to a new hypothesis. Based on his own observations, an increasing appreciation of the stress of trench warfare, and the finding that many shell-shocked soldiers had been nowhere near an explosion but had identical symptoms to those who had, Myers suggested a psychological explanation. For these cases, the term “emotional,” rather than “commotional,” shock was proposed. The psychological explanation gained ground over the neurological in part because it offered the British Army an opportunity to return shell-shocked soldiers to active duty. …

When the United States entered the war in April 1917, U.S. military authorities faced the same steep learning curve. A month later, Maj. Thomas Salmon was ordered to the U.K. and France to study the question of shell shock and make recommendations for U.S. Army policy. In essence, he proposed a system of forward psychiatry supported by a large specialist “clearing hospital for mental cases,” which led to the creation of Base Hospital No. 117, set up at La Fauche. Despite this careful planning, shell shock spread through the American Expeditionary Force and rose to significant levels during the Argonne offensive.

The description of these wounds – and the classification of which elements were psychological and which were “physical” injuries – created debate and controversy, with the former variety “generally seen as a sign of emotional weakness or cowardice. Many soldiers suffering from the condition were charged with desertion, cowardice, or insubordination.”

These early questions about concussion and post-traumatic stress disorder are only beginning to be unraveled by modern researchers, many of whom have discovered that traumatic brain injury and post-traumatic stress can be separate conditions – or closely intertwined.

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

In the next blog in this series, the US enters World War II and rolls out the M1 combat helmet, which would see service with minor changes through Korea and Vietnam.

Previous installments:

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

The American History of Wartime Head Injuries and Helmets, Part 2

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