The American History of Wartime Head Injuries and Helmets, Part 4

“General Dwight D. Eisenhower gives the order of the day, ‘Full victory--nothing else,’ to paratroopers somewhere in England, just before they board their airplanes to participate in the first assault in the invasion of the continent of Europe.” Source:Library of Congress

The war after the “war to end all wars” introduces the M1 combat helmet

The outbreak of World War II plunged the world into the most terrible conflict in history. Approximately 15 million people died in battle worldwide, 25 million were wounded, and 45 million civilians were killed. Estimates vary slightly, but U.S. casualties were about 407,316 killed and 671,278 wounded.

In the run-up to the war, the United States had worked to develop a better helmet that afforded more protection and better comfort:

Between 1918 and 1934, interest and progress in helmet development were maintained by the Ordnance Department and the Infantry Board. Following a series of experimental models (the model 5A was of pot-shaped design and received extensive testing before it was discontinued in 1932) and tests, it was recommended in 1934 that the M1917 helmet with a modified lining of a hair-filled pad be standardized as Helmet, M1917A1.

The final end item with an adjustable headpad weighed 2 pounds and 6 ounces. The US M1917A Transition Helmet was developed due to deficiencies found in the WWI helmet (M1917). The US government used the WWI M1917 helmets and modified them with a new liner system and chinstrap. The M1917A has a hook-and-buckle type securing mechanism, which was the forerunner to the WWII M1 helmets. The helmet shell is smoother and less textured than the WWI M1917 helmets. It has a heavy stitched 2-piece webbed chinstrap. The top of the helmet also has a nut that is used to hold the suspension system (liner) in place. The suspension system is made of four strips bent to act as springs and provided tension to hold the new liner in place. The leather liner consists of 4 leather fingers that tie together. At the center of the helmet is a small leather-covered oval pad that serves as a cushion.

A lull in helmet development occurred in the period from 1934 to 1940 when the first draft call was issued. Before the standardization of the M1 helmet, 904,020 M1917A1 helmet bodies were manufactured from January to August 1941.

The new M1 helmet was introduced in 1941, just in time for the start of America’s involvement in the war:

[T]he Army and several of its research partners rolled out the M1 helmet: which had a slight brim on its front to keep precipitation off a soldier’s face and a slightly lipped rim all the way around. The helmet’s sides also trailed down to cover half a soldier’s ears before dropping down to cover the back part of a soldier’s skull. It also employed a manganese steel outer shell that weighed just 2.85 pounds and an inner molded fiber-plastic liner.

The helmet was considered comparatively heavy but it afforded much greater protection and proved to be a lasting design, serving with minor modifications through Korea and Vietnam.

"Lt. Gen. George S. Patton, U.S. Third Army commander, pins the Silver Star on Private Ernest A. Jenkins of New York City for his conspicuous gallantry in the liberation of Chateaudun, France ... October 13, 1944.” Patton and Jenkins are wearing M1 helmets. Source:The National Archives

Medical advances in World War II

Sir Hugh Cairns was an Australian-born neurosurgeon who pioneered “mobile neurosurgical units that treated casualties with head injuries in the various campaigns fought by the British Army.” He had trained under American neurosurgeon Dr. Harvey Cushing during the previous war, and developed the mobile units “to definitively treat head injuries within 24–48 hours after injury, as Cushing advocated.”

First deployed in 1940, these mobile neurosurgical units (MNSUs) used large vehicles that “had the appearance of a large ambulance or modified truck” and housed a neurosurgeon, a triage neurologist an anesthetist, two nurses, four orderlies, two officers, and two drivers. They could quickly stabilize and start treatment on a patient while delivering him to “a host hospital or temporary casualty clearing station.”

Cairns also established the St. Hugh's Military Hospital for Head Injuries at Oxford. “[A]ffectionately nicknamed ‘the Nutcracker Suite’” the hospital served as the base station for the MNSUs. Staff at St. Hugh's “treated approximately 13,000 head injuries and became a training ground for a generation of neurosurgeons and neurologists, anesthetists, medical students, neurological nurses, orderlies, and other medical personnel.”

Cairns “enforced a meticulous regime of patient care based on Cushing’s principles. His insistence on accurate examination, careful recording and attention to detail led to a high standard of treatment.”

An American counterpart, Dr. Donald Matson, also advocated the value of “far-forward neurosurgery.” At the outbreak of World War II, Matson had left his civilian medical residency to serve as a neurosurgeon with the Fourth Auxiliary Surgical Group in Europe for two years. He outlined four principles of early treatment.

• The immediate saving of life (hematoma evacuation, brain stem decompression)
• The prevention of infection
• The preservation of the nervous function
• The restoration of anatomic structure

Matson’s tenets of treatment endure in modern medicine, and he would later come to be known as one of the “founders of modern pediatric neurosurgery” in his civilian career. 

The advocacy of early treatment and the development of mobile neurosurgical units directly led to the establishment of US Mobile army surgical hospitals (MASH units) that would go on to treat battle casualties in Korea, Vietnam, the Gulf War, and beyond.

In addition, World War 2 physicians developed a greater understanding of explosions and how they caused closed head wounds, an injury which was termed “postconcussional syndrome,” “blast concussion,” and similar names. 

Much like in World War I, physicians focused on differentiating closed head injuries due to physical trauma from similar symptoms that were seen in individuals suffering from what is now known as post-traumatic stress disorder (PTSD):

In each instance inordinate attention was placed on parsing out the neurologic/ “organic” (biomechanical) contributions from the psychological/ “psychoneurotic” contributions, with a reluctance to embrace the possibility that both forms of trauma might operate through overlapping and/or complementary mechanisms.

And like the previous conflict, any differentiation was complicated by the widespread use of explosives and the epidemic of PTSD, the latter of which was then called “battle fatigue” or “Combat Stress Reaction (CSR).” Many military officials still looked at PTSD as if it were a failure of character, such as this example from the Battle of Okinawa:

Some men doubted the validity of battle fatigue, instead questioning the soldier’s manhood. Brig. Gen. Oliver P. Smith, Marine deputy chief of staff for the Tenth Army, at first dismissed most battle fatigue cases as “a good chance to get a five-day rest if your conscience was not too active.” He contended that Marines knew that once they were behind the lines they could enjoy rest, hot food, and hot baths.

In May, however, General Smith investigated a psychiatric hospital where physicians allowed him to observe their treatment to learn more about the issue. One man was brought in who had been recommended for a Silver Star for remaining at his machine gun during one particularly fierce enemy counterattack. After the action ended, Japanese bodies lay on all sides of his post. The man, still trembling even though resting in a hospital, felt such horrid guilt over killing so many humans that he snapped. Doctors told a moved General Smith that the man simply needed a respite from the battlefield and would most likely return to duty in a few days.

About 26,000 soldiers and Marines were treated as psychiatric casualties from the Battle of Okinawa alone, and nearly 1.4 million “soldiers, sailors, and airmen were treated for combat fatigue in World War II.”

Combat exhaustion was responsible for between 40 percent to half of all military discharges in the conflict. These cases were treated and assessed with the principles of Proximity, Immediacy, Expectancy (PIE); which essentially meant quick care with the intent to return recovered troops back to the front lines. It’s unknown exactly how many cases of combat stress were also influenced by exposure to closed head injuries caused by explosions and other means.

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

In the next blog in this series, US combat helmets remain the same but combat medicine evolves with an amazing innovation that speeds front-line care: the helicopter.  

Previous installments:  

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

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

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