Head Protection in England before the First World War

Acute management of military-related injury

Since the dawn of armed conflict head trauma has remained one of the most challenging afflictions for surgeons and medical personnel to treat. Interventions for head trauma from antiquity through the American Civil War were met with dismal outcomes. In the 20th century, despite greater lethality of weapons, progressive advances in management led to improved outcomes for head injured patients. A triage system consisting of appropriate levels of care from the front lines, through combat support hospitals to reconstructive and rehabilitative hospitals, has also contributed to the improved outcomes of head injured patients. This chapter examines the progressive improvement in management strategies during major conflicts, the mechanisms causing head trauma during conflict, and the current medical and surgical therapies recommended in the care of head-injured patients during armed conflict.

The history of military cranioplasty

There is evidence that the neurosurgical procedure of cranioplasty is as ancient as its better-known counterpart, trephination. With origins in pre-Incan Peru, cranioplasty remains an important reconstructive procedure for modern craniofacial surgery teams to master. Solutions to the often challenging problem of repairing skull defects continue to evolve to improve patient outcomes. Throughout recorded history, advances in cranioplasty have paralleled major military conflicts due to survivorship after trephination or decompressive craniectomy. Primitive skull coverings used in Peru were later replaced during the Middle Ages by grafts obtained in animals and humans. Improved survivorship secondary to advances in anesthesia and battlefield medicine during the Crimean War and the American Civil War allowed the use of tantalum and acrylic cranioplasty to evolve during World Wars I and II. In the modern era of the Iraq and Afghanistan conflicts, greater survivorship after cranial injury due to improvements in protective armor, medical evacuation, and early “far-forward” neurosurgical treatment have occurred. Consequently, the last decade has seen great advancement in cranial defect reconstruction, including custom-fabricated alloplast implants and the emergence of regenerative cranial treatments such as distraction osteogenesis, protected bone regeneration, and free tissue transfers. Comprehensive rehabilitation after neurotrauma has emerged as the new standard of care.

Chapter 53: rehabilitation therapies

This chapter retraces the history and evolution of rehabilitative efforts by physicians and other health professionals to alleviate the symptoms and disabilities associated with neurological disorders. Rehabilitation therapies often provide interventions that go beyond traditional medical treatment aimed at treating impairments, and help those with neurological injuries and illness to re-establish themselves as productive and socially-integrated citizens by reducing their functional disabilities. The chapter considers the early history of practical treatments developed in Greek and Roman times, reviews the scattered attempts at treatment during the Middle Ages and Renaissance, examines the more recent development of specific rehabilitative techniques and disciplines in the 20th century, and also provides discussion of the contemporary application of empirically validated rehabilitation strategies and techniques that emphasize treatment efficacy. The evolution of medical and physical rehabilitation, occupational and vocational rehabilitation, aphasia and cognitive rehabilitation, are all discussed, with additional review of the influence of some of the military conflicts and wars in history that have stimulated the advancement of the clinical practice of rehabilitation. A critique of the benefits of comprehensive rehabilitative programs for traumatic brain injury and stroke is specifically included. The varied skepticism and optimism of treating neurological disorders throughout history is also highlighted.

The Kabuto, or the Japanese helmet: evolution from war implement to status symbol

WARRIORS THROUGHOUT THE AGES have considered the unprotected head to be particularly vulnerable. The traditional Japanese helmet, the Kabuto, was the part of a protective suit of armor that reflected the wearer's character and personality. Over time, it changed from a primarily protective device to a vehicle for the expression of a distinctly Japanese sense of magnificent artistry. Each Kabuto was custom-made, and these helmets remain without peer in the world. They were designed and crafted to answer the demands of their era, and thus they provide historical evidence not only of the state of Japanese warfare, but also of social organization, metallurgical knowledge, artisanship, and aesthetic sensibility. Even now, during the national Golden Week Festival in early May, Kabuto are displayed in the alcoves of Japanese homes as a petition that the boys in the house be granted courage and good health. Thus, even in modern Japan, the Kabuto represents a talisman. We present an overview of the evolution of the Kabuto, with special reference to the Japanese sword and the warrior tradition.

Lawrence of Arabia, Sir Hugh Cairns, and the origin of motorcycle helmets

When Colonel T.E. Lawrence ("Lawrence of Arabia") was fatally injured in a motorcycle accident in May 1935, one of the several doctors attending him was a young neurosurgeon, Hugh Cairns. He was moved by the tragedy in a way that was to have far-reaching consequences. At the beginning of the Second World War, he highlighted the unnecessary loss of life among army motorcycle dispatch riders as a result of head injuries. His research concluded that the adoption of crash helmets as standard by both military and civilian motorcyclists would result in considerable saving of life. It was 32 years later, however, that motorcycle crash helmets were made compulsory in the United Kingdom. As a consequence of treating T.E. Lawrence and through his research at Oxford, Sir Hugh Cairns' work largely pioneered legislation for protective headgear by motorcyclists and subsequently in the workplace and for many sports worldwide. Over subsequent decades, this has saved countless lives.