HELMETS IN SURGICAL HISTORY

Aust. N.Z. J . Surg. (1996) 66, 314-324

SURGICAL HISTORY

HELMETS IN SURGICAL HISTORY

DONALD SIMPSON National Health and Medical Research Council, Road Accident Research Unit, University of Adelaide,

Adelaide, South Australia, Australia

The relevance of historical experience is evident in a consideration of helmets designed for head protection i n war, industry, sport and road transport. Modern helmets are designed to minimize the risk of brain damage by penetration and by blunt impact; where facial or ocular injury is likely, facial protection may be provided by visors, goggles or full-face helmets. The effectiveness of helmets should be monitored by studies of actual injuries; historically, surgeons have done this, in war and peace, for centuries.

Key words: eye injuries, head injuries, head protective devices, history of medicine, occupational safety, sports, vehicles.

HERBERT MICHAEL MORAN, 1885-1945 The Herbert Moran Lecture in Medical History commemorates one of the most remarkable Fellows of the Royal Australasian College of Surgeons, a man distinguished in his day as a pioneer in surgical oncology and as an elegant writer. The lecture was endowed by Moran’s father, shortly before Moran himself died of disseminated melanoma.

Moran’s vivid and sometimes stormy career was reviewed, with tactful reticence, by John Loewenthal,’ largely on the basis of Moran’s own accounts of his life, and also by Bernard O’Brien.? Sir Douglas Miller has written a much shorter and more incisive account, which does full justice to Moran’s surgical skills and literary distinction, and to his warmth and kindness, but also makes clear that he was hypersensitive, prone to umbrage, and given to premature resignations from hospital appointments.’

Towards the end of his life, Moran wrote two autobiographical book^^.^ and a novel with the splendid title Beyond the Hills Lies China,h which is clearly in part autobiographical. He also wrote an interesting and perceptive book, Letters from Rome, which is valuable as a contemporary picture of Mus- solini’s imperialism, as seen by a man who loved Italy but was not blind to her leader’s deficiencies,’ In these books, there is a shining conviction of the importance of national and medical history in the shaping of a surgeon’s philosophy. Moran claimed to have founded the first Australian society for medical history and literature4J and to have obtained for the Royal Australasian College of Surgeons the Cowlishaw collection of historical medical books.y The College also owes him a very great debt, for the lecture that commemorates him, a lecture that has led many surgeons over the last 50 years to look at the role of creative time in the evolution of modern surgery.

Correspondence: D. Simpson. NHMRC Road Accident Research Unit.

Presented as the Herbert Moran Lecture I I May 1995.

Accepted for publication 23 August 1995.

University of Adelaide, GPO Box 498. Adelaide, SA 5001, Australia.

HELMETS IN HEAD PROTECTION The brain can be injured in many ways. Sharp objects, like the edge of a sword or a piece of windscreen glass, can penetrate the skull and cut into the soft, easily wounded brain. This dis- aster may be prevented if a hard protective plate covers the skull to blunt or deflect the edge of the weapon. Such a plate may stop an arrow, bullet or bomb fragment.

A blunt object, like a stone or a club, may shatter the skull, and damage the underlying brain. A hard plate may prevent this damage by distributing the force of impact over a wider area. Unless the hard plate has padding underneath it, the impact can still be injurious: the impacting force may cause more distant brain damage, by setting the brain in movement within the skull.

The brain may also be injured without any skull fracture, when the moving head is very suddenly brought to a halt. This happens when an unbelted car occupant, or an unhelmeted motorcyclist, is thrown on the road, or against some rigid com- ponent of the car. The resulting injuries often include diffuse axonal and vascular brain damage, resulting in death or disabilities of many kinds. The mechanisms of blunt head impacts are very complex, but brain damage can be reduced if a helmet is designed to cushion the impact and to bring the head to rest more gradually.

The eyes are even more vulnerable than the brain. The eye may be penetrated by sharp objects and missiles, and the nerves of the eyes may be crushed if the skull base is shattered, pos- sibly resulting in blindness. The facial tissues may be injured by sharp or blunt objects, and the effects can be painful and even disabling. Blindness and facial injury can be prevented by a helmet, if it covers the face.

HELMET DESIGN To protect the brain, a helmet should be hard enough to prevent penetration, yet soft enough to cushion the head against blunt impact. In modern helmets, this contradiction is usually resolved by an outer hard shell, and an inner lining able to absorb energy by crushing on impact. In addition, a helmet should not be knocked off on the first impact, since

HELMETS IN SURGICAL HISTORY 315

there may soon be a second impact. Other helmet requirements are that the helmet should be comfortable, weatherproof, and well ventilated. In some situations a conspicuous helmet is desirable, as a rallying point in close combat; for a sniper, the reverse is true. All these considerations, and several more, can be seen in the minds of helmet designers over the last 4000 years (Table I) .

HELMETS IN WAR Ancient Mesopotamia

In the Sumerian trading cities of Mesopotamia, now Iraq, helmets were used for head protection at least as early as the third millennium before Christ. About 2600 BC, a prince of Ur, named Meskalamdug, was buried with a magnificent helmet made of electrum, a natural gold-silver alloy (Fig. 1 ) . This may have been used for decorative or ceremonial purposes. But the soldiers who were buried with him in a most convincing gesture

Table 1. Components of protective helmets used in war, sport, industry and road traffic

Outer shell Inner lining Retention Metal Plastic Ancient Modem device

Bronze Polycarbonate Wool Cradle of straps Chin strap Iron Fibreglass Cotton Cork Steel Kevlar Leather Polystyrene foam

Felt Air bag

of loyalty, wore copper helmets“’ which must have had protective value.

Copper is a soft metal, but the addition of tin gives bronze, which is much harder. In the second millennium BC, the Indo- European peoples of Asia Minor wore helmets in war: this is evident in the art of the Hittites, pioneers in metallurgy. Helmets are still more obvious in later Assyrian scuIptures.11J2 Sculptured representations do not allow deductions on the protective value or composition of a helmet, though as iron was still a rare metal it is likely that the helmets were made of some less precious material, such as bronze.

Greece and Rome The Mycenean Greeks certainly used bronze helmets, as early as 1400 BC.I3 Homer’s great poem the Iliad,14 variously dated between 650 and 900 BC, contains many descriptions of bronze helmets and leather protective caps. In battle, Homer’s aristocratic tribal leaders wore bronze helmets, plumed with horsehair and secured with a leather chinstrap. However, on a night raid, that wily man Odysseus wore a padded leather cap strengthened with a row of boar tusks: a form of head protection known from Mycenean tomb finds some 6 centuries before Homer’s time. Presumably the cap was less conspicuous.

The bronze helmets were not always successful. Homer describes 14 examples of impact on a helmeted head, inflicted by various weapons: swords in three cases, stones in three other cases, and spears in eight (Table 2). No arrow hits on a helmeted head are mentioned; of the 19 arrow injuries described in the Iliad, only two are in the face or neck, and it does not appear that the arrows hit in an area covered by a helmet. These descriptions are so vivid that it is tempting to accept them as clinical descriptions.lS This temptation should be resisted. Homer was a very great poet, not a military stat- istician; moreover, he was describing events already centuries old. Yet it is worth noting that in 10 cases the impacts were immediately lethal; one victim was temporarily unconscious, and three were unaffected. In two of these lucky fellows, the assailant’s bronze sword broke on the helmet. It seems reasonable to deduce that Homer expected his audience to believe that a good helmet may turn a sword or an arrow, but will not save you from a direct hit by a heavy javelin thrown by a muscular lout like Achilles.

A century after Homer’s time, Greek military tactics changed towards the use of strike forces of citizen soldiers closely formed in an eight-deep phalanx.I6 These heavily armed infantrymen wore so-called Corinthian helmets giving almost complete craniofacial protection (Fig. 2). Such a helmet is pre- served in the Adelaide University Classical Museum. It is made of bronze hammered from a single sheet. It gives full facial protection except for the eyes and it is 1.1-1.5 mm thick,

Table 2. Impacts on helmeted heads in the Iliad

Outcome Sword Stone Spear

No clinical effect 2 0 1

Brief loss of consciousness 0 0 1 Fig. 1. Sumerian helmet, made Of a natural silver-gold alloy, simu- Immediate death 1 3 6 lating the hair and ears of the prince who wore it. The holes at the Total 3 3 8 margins suggest a lining, probably with padding. Courtesy of the British Museum.

(sword broken)

No arrow impacts on helmets have been identified.

316 S IM PSON

Fig. 2. Helmet of Corinthian type. Courtesy of the Museum of Classical Archaeology, University of Adelaide.

perhaps more over the vertex. There are holes which suggest stitches to secure internal padding. It has attachments for a crest, perhaps of horsehair, for decoration and perhaps as a rallying marker; such helmets typically weighed about 1.5 kg.I7 It is easy to believe that the Corinthian helmet would give considerable protection against a sword slash, arrow or spear thrust. The degree of protection against blunt impact is uncertain since the thickness and nature of the padding are unknown; felt has been suggested. The helmet must have limited the wearer's

vision and, except when in combat, the wearer pushed the helmet back on the head like a pair of sunglasses.

Roman legionary soldiers also used bronze helmets. These gave less facial protection, but had hinged cheek guards and a projecting flap behind to protect the neck. Traces of helmet linings have been found in Roman helmets; Robinson18 deduced that these helmets were padded with quilted material, perhaps containing wool or straw. Wool, tightly packed, would have some value as protection against blunt impacts. Roman troops also used iron helmets at various times. Graeco-Roman surgeons must have been familiar with the role of helmets in head protection, especially those with military experience, or those who like Galen himself studied the head injuries of gladiators.

After Rome In the Dark Ages that followed the collapse of the Roman Empire, iron helmets were increasingly used, combined with ring mail for neck protection. Iron is less easily worked than bronze; it can be cast, but cast metals are usually brittle. Helmets were therefore made of iron plates riveted together. A magnificent Anglo-Saxon helmet was found in a well in the city of York;" it is supposedly dated about 750 AD (Fig. 3a). It comprises an iron cap made of eight bands or plates riveted together. The plates vary in thickness, ranging up to 3 mm. There are hinged cheek plates, as in Roman helmets, and these are also of iron, 1.4-1.8 mm thick. The iron has a low carbon content, corresponding with modern mild steel, annealed and hammered into shape when hot.

The helmet was certainly padded, but the nature of the padding is unknown. Such a helmet would have considerable protective value, and this helmet showed indeed a dent in the front, perhaps caused by an armour piercing arrow or a javelin (Fig. 3b).

Fig. 3. Anglo-Saxon helmet, found in Coppergate, York, UK. (a) Right side. (b) Left side, showing dent (arrow) attributed to missile impact. Courtesy of the York Archaeological Trust.


Helmets were developed in China, Japan and the Islamic world and quite independently in Pre-Columbian America?” and in some of the Pacific Islands.

The Middle Ages The armoured horseman dominated the social and military scene throughout the Middle Ages, both in Europe and to a considerable extent also in Asia. Mediaeval barons and knights could afford expensive helmets giving full facial protection at the cost of visibility and ventilation, and their horses could carry the additional weight. Helmet designs reflected the local climate as well as the technology available locally. In the Middle East, Saladin and his emirs wore open-faced helmets, often with chain-mail neck protection (Fig. 4). Their adversaries the Crusaders were more heavily armed. The Teutonic Knights, spreading the gospel in the Baltic area, wore big full-face helmets weighing up to 9 kg; the Templars and Hospitallers in the Holy Land preferred open-face helmets with more ventilation?’

The advent of firearms Even in the Middle Ages, armoured horsemen were challenged by missiles: arrows from the English longbow or the Turkish mounted archer; slingshots; and crossbow bolts with considerable penetrating power. The advent of gunpowder brought in a new challenge. In the fifteenth century, handguns and cannon were often used (Fig. 5 ) . In the Hussite wars, the Czechs, an inventive people, used guns to good effect against German

clash with Henry VIII’s forces near Boulogne in 1545.?* This brilliant and, to his adversaries, sinister soldier-politician was hit above the right eye by a lance, which ran obliquely across his face to emerge at the back of his head behind his left ear. The lance-head stuck fast and had to be pulled out with pincers by his surgeon, Monsieur Lavernon, who had to brace his foot against the ducal head to do so.23 Guise survived with no dis- ability, but he got his nickname Le Balafr6, Scarface, because of the resultant scar. Par6 clearly related this wound to the Duke’s practice of fighting ‘with open-face’;22 presumably he wore a helmet without facial protection. A wartime injury typical of this period is illustrated by the helmet of the Consta- ble of France, Anne de Montmorency, a Catholic leader in the Huguenot civil wars that lacerated France in the second half of the century (Fig. 6). The pugnacious old man (he was 69 years old) was shot in the battle of Dreux (15621, through the visor of his helmet, by an arquebus bullet; he sustained a jaw injury, but made a rapid recovery, only to die of a spinal bullet wound in a later civil war. It is unfortunate that Par6 was not present to describe this wound, but in view of the Constable’s rapid recovery it seems likely that the visor absorbed much of the bullet’s impact energy.

Military helmets remained in routine use for the next 2 centuries. A popular army drill book published in 1632 shows a heavy cavalryman firing his horse pistol with his visor down, and then reloading with his visor up.24 Pistol drill was compli- cated and could go wrong. In 1641, the Comte de Soissons inadvertently blew out his brains by pushing up his visor with a loaded pistol. Or so it was said; there are other stories.25 The increasing efficiency of firearms led to a progressive decline in

knights. In spite of what is often written in disparagement of the early handguns, it is significant that in standard tests of commercial body armour the gun soon replaced the crossbow as proof of the quality of iron or steel plate. The discerning buyer of a breastplate looked for a bullet dent as proof that the plate had stood up to a standard test, a pistol shot fired in the workshop under agreed conditions.

In the 16th century, professional soldiers continued to use iron helmets, and references to these appear in the vivid writings of contemporary surgeons. Ambroise Par6 describes in detail a facial wound suffered by Francois, duc de Guise, in a

Fig. 5. Handguns and helmets in 1475. In this woodcut of the siege of Neuss am Rhein. two German gunners are menacing a Burgun- dian archer. Most of the soldiers wear helmets. On the right is a cavalryman with a visored helmet.

Fig. 4. Saracens in helmets. Saladin and his men, from a modern statue in Damascus, Syria.

318 SIMPSON

Fig. 6. Helmet (bourguignotte type) worn by the Constable of France, Anne de Montmorency, at Dreux, 1562. There is a bullet hole in the visor. Courtesy of the Curator of the MusCe de I’ArmCe, Paris.

Fig. 7. French cavalry helmet, worn by a trooper in General Bona- parte’s army in Egypt, circa 1800. Courtesy of the Adelaide Club.

the use of armour, but as late as Waterloo helmets were retained as protection against a sword slash in cavalry encounters. The French heavy cavalry who charged Wellington’s guns at Water- loo wore helmets (Fig. 7), and also cuirasses; it was such cuirasses that Bonaparte’s surgeon Baron Larrey used as pans to heat up horse soup for his wounded patients after the French defeat at Aspern-Essling in 1 809.26

The advent of high velocity rifles seemed to make helmets a needless encumbrance, and they were little used in the American Civil War and the Boer War. Ned Kelly was either premature or anachronistic in equipping his gang with body armour; his own suit is said to have weighed 92 Ib, the helmet weighing 16 Ib, and although the body armour resisted penetration well, it is recorded that the wearers suffered intensely painful bruises when hit by bullets, perhaps from inadequate padding.*’

World War I When the First World War broke out, British and Australian soldiers at first went to their deaths wearing cloth caps or hats. French soldiers wore soft kCpis, German soldiers caps or pressed leather helmets (the well-known Pickelhauben). But to the surprise of military experts, the First World War brought back the helmet. Trench warfare and the increasing use of frag- mentation missiles bursting in the air, such as shrapnel shells and hand grenades, led to large numbers of head wounds from relatively low velocity missiles. A French officer, Colonel A. Adrian (later Intendant General) saw the need for head protection. After trial of a steel skullcap, the French army was equipped with the casque Adrian, made of mild steel about I mm thick. Wartime French medical literature has many trib- utes to the protective value of these helmet^.^^.*^ Clovis Vincent, later a founder of French neurosurgery, was among the early advocates of the steel skullcap.28

On the German side, the chief advocate for head protection was Professor August Bier of Berlin..”’ He was a senior naval surgeon, but on a visit to the Western Front he studied a series of head injuries, and was appalled by the cerebral disabilities. In collaboration with Captain Friedrich Schwerd, a professor of engineering then serving as a Landwehr officer, Bier introduced a chromium nickel steel helmet, the well-known coal scuttle helmet, famous in both world wars (Fig. 8). The British found that a manganese steel helmet performed better in tests, and brought in the helmet used by our troops in both world wars. In the test situation this helmet, which was a little less than 1 mm thick, would stop a shrapnel ball weighing about 1 1 g at a velocity of about 225 m/s,31 or a pistol bullet.

These helmets were not unduly heavy: the British and German helmets weighed about 1 kg, the French helmet rather less. Steel helmets were not expected to stop a rifle bullet and their failure to do so is seen vividly in a paper describing 250 head wounds sustained in the appalling battles for Pas- schendaele, written by Harvey C ~ s h i n g . ~ ~ Cushing was then unchallenged as the greatest neurosurgeon of the day; working in a hospital often threatened by bombing, and sometimes oper- ating by candlelight, he nevertheless found time to keep metic- ulous notes, and to record wherever possible if his patient had worn a helmet. It appears that most of the survivors did wear helmets, which were often perforated by shell fragments or shrapnel balls. But this tells us nothing, since the impact veloc- ities are unknown. The steel helmet was also of some use against blunt impacts, having a webbing cradle that distributed the load over a wide area, and by stretching reduced the impact force transmitted to the head.

The British helmet gave less protection against horizontal fire than the German helmet, and was criticized because it gave no cover for the side and back of the head. Several of Cushing’s cases had brain wounds from missiles entering below the helmet brim.

Modern war In the Second World War, the US armed forces used a helmet giving better all-round protection. Today, helmets remain in military use, though steel has been replaced by Kevlar,* a plastic composite giving better protection weight for weight (Fig. 9). Helmets worn in the Gulf War were used in conjunction with eye

*Kevlar aramid, du Pont Fibers, Richmond, Va, USA.


Fig. 9. Modern Kevlar helmet. Soldiers now wear polycarbonate goggles, as protection against small missiles and laser beams. Courtesy of Col. P. D. Byrne, RAAMC.

and mining industries. These trades are both very ancient and very dangerous, but it is hard to find early references to head protection. In the great Polish salt mines at Wieliczka, near Cracow, rock salt has been mined for some 700 years, since the time of the blessed Queen Kinga and her husband Prince Boleslaw, known as Boleslaw the Bashful or the Chaste, from his invincible chastity. Head injuries must have been frequent, and the mines employed surgeons from AD 1499.33 Contem- porary pictures of Polish and German miners suggest that head protection took the form of caps or hoods at least as late as the 18th century. Sir Arvi Parbo says that hard hats were not common in Australia until the 1 9 3 0 ~ , ~ ~ and it seems that this was also true of English coalmines. But Cornish tin and copper miners certainly took to using protective hats made of leather or felt hardened with resin well before this. In 1877, Hudson, a surgeon working in Cornwall, emphasized that hard hats were in general use, and described a community with a strong interest in head injuries and their surgical treatment.35 When an injured miner was in his care, he was commonly asked: ‘When will you bore ‘un?’

Modern industrial helmets are commonly made of fibreglass or a plastic material. Hitherto, these have been designed to give protection against sharp or blunt impacts from above,36 such as falling objects, and they rely on a cradle of straps to cushion the impact. They are not designed to give protection against lateral impacts, as experienced in a fall (Fig. 10); however, helmets giving more comprehensive head protection are under study.37

Fire fighting is another industry requiring head protection, and in the past, military-style brass helmets were standard equipment in many countries. Modern fire brigade helmets have an energy-absorbing liner and a detachable Outer shell, to

that the fireman is not trapped by the helmet ( ~ i ~ . 1 l).The helmet and its straps must be heat-resistant and, like other industrial helmets, must be insulated against electric current. For bush firefighters, these helmets may be too heavy.

Fig. 8. Chman steel helmet, supposed to be 1916 Pattern. (a) Profile view. The hole allowed attachment of a frontal re- inforcing plate that was later discarded. (b) Interior, showing padding (not original pattern).

protection by polycarbonate goggles Or vi~ors. Probably these saved many eyes from penetration by missiles or sand particles.

HELMETS IN INDUSTRY HELMETS IN SPORT

Today helmets are used in various sports, the design of the Industrial accidents are doubtless as old as the pyramids. Today, industrial helmets are widely used, especially in the building

helmet varying with the risks of the sport. Sports entailing violent combat, such as jousting, boxing and football, present

320 SIMPSON

Fig. 10. Modem industrial helmet. The wearer fell approximately 15 feet, and sustained a skull fracture and extradural haematoma, probably from an occipital impact. This type of helmet is not designed to protect against these impacts.

very demanding requirements in helmet design. In the case of jousting, full-face helmets were used, more or less of military type, although in this aristocratic sport the impacting force was from a blunt lance rather than an armour-piercing missile. Acci- dents happened even with the best helmets. Par6 described the death of King Henri I1 in 1559 in a sporting The

athletic king was jousting with his Captain of the Guard, and was hit on the chest with a lance. The shaft of the broken lance shot upwards, forced the king’s visor open, and impacted on the left orbit, leaving many splinters. The king did not at first lose consciousness,2” but his condition later worsened and he died 1 I days later despite the anxious care of Ambroise Par6 and Andreas Vesalius. It seems likely that death was from sup- puration rather than from the contrecoup subdural haematoma that Par6 found at autopsy. Par6 also described another very similar tilting accident in which a nobleman had the misfortune to get a lance splinter through his visor and into the orbit; with Pare’s help, God’s favour and the collaboration of a medical team, the victim recovered.22

In boxing, the chief fun of the game is the spectacle of a man being battered by head impacts, and it is understandable that helmets have little appeal. In this, boxing contrasts with Roman gladiatorial sports, where some participants did wear elaborate helmets. Surgeons and neurologists throughout the world have condemned boxing because it is a proven cause of acute and chronic brain damage.

In football, helmets have long been used in the American version of the game. This vigorous sport took off soon after the American Civil War, the first intercollegiate game being in 1869. At first, a few injuries were seen as an acceptable price to pay for the benefits of a game that fostered virile qualities. However, in the 1905 season there were 23 deaths, and this did cause some concern. Safety was sought in protective armour, and initially leather helmets were used; these were progres- sively improved, and became compulsory between 1939 and 1943.38 With these, the combatants became more confident and even more ferocious, especially in tackles, and over the next 40 years the annual death rate remained fairly constant at about 2.6 deaths per 100 OOO players, or about 25 deaths a season.39

The Scottish novelist Eric Linklater was a war veteran; serving in the Black Watch, he had suffered a head wound in 1918. But even with this experience behind him, he was impressed by the violence of the American game and the dedi- cation of the players. In his novel Juan in America, he made a football coach train the players in tackling oak trees until there were no trees left for miles around.40 After the Second World War, rigid plastic helmets were introduced, with visors for face protection. The results were unsatisfactory. In 1964, Richard

Fig. 11. Modern firefighter’s helmet showing (a) visor and (b) detachable energy-absorbing lining. Courtesy of Mr M. Smith, United Firefighters Union of Australia.

HELMETS IN SURGICAL HISTORY 32 1

Schneider, an American neurosurgeon, reported on 225 serious or fatal football injuries of the spine or head, collected over a 5 year period?' He found that nearly 90% occurred in players wearing the full panoply of helmet and body armour. The risks appeared to be much less in football played without armour. Admittedly, such amateur games were usually less ferocious than college or professional football, but Schneider questioned whether the armour was the cause of injury; a reasonable question in view of the then current practice of spearing, butting the enemy with a helmeted head. Schneider's writings did much to make football combat less dangerous. With less lethal tactics and better helmets, the mortality has steadily fallen?* This is a historic example of a successful surgical intervention in public health.

Today, helmets and visors are standard equipment in cricket, ice hockey, baseball and several other sports in which missile injury is likely. Helmets were apparently first used in World Cup cricket in 1977-78, and today batsmen normally wear hard hats and facial visors. Helmets are not used in golf, a game in which spectators are chiefly at risk.

HELMETS ON THE ROADS Helmets came into use for flying, motor car and motor cycle racing before the First World War. As early as 1909, a motorcyclist who came off at 60 mph attributed his survival, rightly or wrongly, to his leather helmet. In 1914, the Auto Cycle Union made helmets compulsory in speed and when the Second World War began in 1939, the British Army had some crash helmets available for use by motor cyclists (Fig. 12). These were of two types. One had a shell of vulcanized rubber, with a webbing cradle inside the helmet to distribute the load of an impact. The other was similar, but had a shell of wood pulp. These helmets, however, were not widely used, and in the first 21 months of the war there were 2279 motor cycle related deaths in Great Britain: 21% more than in the corresponding peacetime period."

The need for motor-cycle helmets was seen most clearly by an Australian surgeon, Hugh Cairns, and it was he who made

RUted Cork Rim

podded &ft Leather

Fig. 12. Early motor cycle helmet, circa 1924. Courtesy of the Brooklands Gazette and the National Motor Museum, Beaulieu.

them compulsory in the British Army, in November 1941. The nature and remarkable scientific depth of his achievement is not always understood.

Hugh Cairns (1896-1952) was a South Australian medical graduate, born in Port Pirie. His neurosurgical career has been well told in a fine biography by Fraenkel.45 Soon after the out- break of war, Cairns became Consultant Neurosurgeon to the British Home Army, with the rank of Colonel and later Briga- dier. He set up a military hospital for head injuries in St Hugh's College, Oxford, which opened in February 1940. In this hospital, he was appalled by the high death rate among motor cyclists, and he was struck by the lesser severity of the head injuries among the few helmeted motor cyclists. His first published paper on this theme appeared in BMJ in October 1941." This observation could have been made by any observant surgeon; Fraenkel has speculated that it may have been primed by Cairns's knowledge of the death 6 years earlier of TE Lawrence, Lawrence of Arabia, who had died from an unhelmeted head injury when he lost control of his motor cycle. It was, however, the special achievement of Hugh Cairns that he subjected his intuitive deduction to scientific analysis of the highest order. In this he was assisted by a physicist who was also a motorcyclist, and their partnership is one of the most fruitful in surgical history.

AHS Holbourn (1907-62) was a Scottish physicist, aged 32 when the war broke out. A graduate of Edinburgh University, he took an Oxford Doctorate of Philosophy in 1937, after studies on the angular momentum of light, supervised by Pro- fessor FA Lindemann, later famous as Churchill's scientific adviser and ennobled as Lord Cherwell. Cairns enlisted Hol- bourn in studies of the biophysics of head injury, and thus Hol- bourn entered his brief but creative career as a pioneer of modern thinking in this field. It was a gift of Cairns that he would look at the work of some young scientist in a different field, would infect that man or woman with his own enthusiasm, and would then open up a new scientific career.

Holbourn and Cairns used road accident data, collected under all the difficulties of war, to confirm the value of mandatory crash helmets, and this became evident in the fall of deaths during the war years. They showed that the head impacts suffered by motorcyclists are often frontal, sometimes lateral, and very rarely on the vertex. They showed that the suspensory harness was best able to absorb the energy of an impact on the crown of the head, and least effective where impacts were com- monest. They further showed that of the two helmet types then in use, the pulp helmet was considerably more effective, and they emphasized the key role of the energy-absorbing inner

These wartime observations were later confirmed, notably by research at the British Road Laboratories at Har- mondsworth, where the inspiration of Cairns was acknowledged after his premature death in 1952.48

Holbourn did much more than validate the utility of crash helmets. In a few elegant papers, he established on theoretical grounds that the chief injurious force in closed head impacts is shearing of brain tissue, resulting from angular acceleration imparted to the semifluid brain t iss~e.4~-~ ' He formulated the concept of rotational energy as a cause of brain damage, and showed in gelatine models that the internal configuration of the skull would focus this energy on the temporal lobes and the undersurfaces of the frontal lobes, where autopsies, and now CT scans, show indeed a high frequency of damage. Holbourn left Oxford in 1947, and took an appointment as Lecturer in

322 SIMPSON

Fig. 13. Modern open-face helmet in (a) external view and (b) longitudinal section. Reproduced with permission from Craniomaxillofacial Trauma, edited by D. J. David and D. A. Simpson, Edinburgh: Churchill Livingstone, 1995.

Fig. 14. Modern full-face helmet in (a) external view and (b) longitudinal section. Reproduced with permission from Craniornaxillofacial Trauma. edited by D. J. David and D. A. Simpson, Edinburgh: Churchill Livingstone, 1995.

Fig. 15. Modern pedal-cycle helmet in (a) external view and (b) longitudinal section. Reproduced with permission from Craniomaxillo- facial Trauma, edited by D. J. David and D. A. Simpson, Edinburgh: Churchill Livingstone, 1995.


Natural Philosophy in Aberdeen University. He died at the age of 54.

After the war, experimental work in England and elsewhere established that a motorcyclist’s helmet should have a hard outer shell, and the favoured materials are fibreglass and polycarbonate (Table I ) . More importantly, there should be an energy-absorbing inner layer, and the favoured material is polystyrene foam, with properties designed to reduce the crash impact force transmitted to the brain to a tolerable level. Foamed polystyrene came into favour in the 1960s because it is cheap, light, and not elastic: foam liners crush, absorbing energy, without much elastic recoil (Fig. 13). Much work has been done to establish the best trade-off between helmet weight and size, safety benefit, and user’s acceptance.

Full-face protection for motorcyclists became popular after 1970 and their merits are still under debate. The full-face struc- ture (Fig. 14) protects the facial skeleton, and gives some protection to the cervical spine, but it has been argued that the full-face design may allow the energy of a facial impact to be transmitted directly to the skull base and so to the brain.s2 Full- face helmets are uncomfortable in hot weather, as Crusaders in the Holy Land no doubt knew, and one rarely sees such helmets on Asian motorcyclists.

Helmet use by motorcyclists became mandatory in Victoria in 1961, and by 1974 was legally compulsory in all Australian states. The benefits were firmly established by Foldvary and Lane.53 However, the protective value of helmets was more dra- matically demonstrated by a controlled social experiment carried out by legislators in 26 States in the USA. Civil liberty lobbyists brought about the repeal of helmet enforcement leg- islation, and were rewarded by a massive increase in motorcycle deaths, from which it was possible to establish that helmets reduce mortality by 28 t 8%.54 It is interesting to speculate on the attitude of an ethics committee to a similar experiment con- ducted on any animal other than man.

In the last few years, Australia has taken the lead in making pedal-cycle helmets mandatory, first in Victoria in 1990 and now throughout the Commonwealth. These helmets are similar in principle, but lighter and as a rule give less complete protection (Fig. IS).

CONCLUSION Historically, helmets have been used for at least 4500 years to protect the brain, the eyes and the face. Surgeons have appeared in the history of helmets, since surgeons see the failures and limitations of helmets, and experience the sorrow and frustra- tion that accompanies death, blindness or brain damage that could have been prevented. In the 20th century, surgeons such as August Bier, Hugh Cairns and Richard Schneider have been forerunners in head injury prevention. In Australia, their work has been carried on by many surgeons, notably the late Kenneth Jamieson and Borys Selecki. More recently, McDermott and Klug have been leaders in the campaign for pedal cycle safety.s5

Helmets today are still far from satisfactory. They could be more comfortable, they could give shade and they could stay on better. Helmets for children need more thought. There is concern in Sweden over deaths in young children from hanging in helmets worn when climbing in trees and other unpredictable

The pros and cons of full-face helmets for motorcyclists need further consideration. More fundamentally, there is a need to know whether more deaths from diffuse brain injury

could be prevented by helmets with different capacities to absorb energy. It is disconcerting that John Lane, pioneer in the evaluation of helmet benefits, has found no convincing increase in the percentage of lives saved by motorcycle helmets during the last 30 years, despite much work on helmet design.s7 This may well express the limitations of modern helmets in reducing rotational acceleration after head impact, the importance of which Cairns and Holbourn emphasized some SO years ago. These challenges call for continued multidisciplinary research, by engineers, physicists, epidemiologists, and, as in the past, by surgeons.

ACKNOWLEDGEMENTS Many people have helped in this review. I thank especially Dr A. J. McLean and my colleagues in the NH&MRC Road Acci- dent Research Unit, and Ms Paula Maxwell of the Museum of Classical Archaeology, University of Adelaide; Colonel P. D. Byrne, RAAMC; M. J.-P. Reverseau and his colleagues of the MusCe de I’ArmCe, Paris; Dr R. Wirtgen of the Bundesamt fur Wehrtechnik und Beschaffung, Koblenz; the British Museum; and with particular warmth Mr D. I. Penn and his colleagues of the Imperial War Museum, London. I am indebted to Mr Barry Grieger of Medical Photographics for much help with the illustrations.

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HELMETS IN SURGICAL HISTORY