Football concussions not new problem
By Deborah Blum
MADISON, Wis. — The warning in The Journal of the American Medical Association is not ambiguous: "There is a very definite brain injury due to single or repeated blows on the head or jaw which cause multiple concussion hemorrhages. ... The condition can no longer be ignored by the medical profession or the public."
The report in question concerns professional athletes, hardly surprising given the worries expressed during last week's Super Bowl runup and Congressional hearings into long-term damage caused by football-related concussions. It methodically details the well-publicized problems — loss of coordination, cognitive deficits, uncontrollable rages — that forced the NFL to issue new rules this season limiting players with head injuries from returning to the field.
But what really makes the research and its conclusions so interesting is its timing: It appeared in The Journal of the American Medical Association on Oct. 13, 1928. This raises the question — at least for me — as to why we are announcing the athlete concussion-dementia link as a new, and still somewhat debatable, issue some 80 years later.
It was only in December that the NFL finally conceded publicly that concussions "can lead to long-term problems." And even that admission was contradicted a few weeks later by one of the league's longtime brain injury experts, Dr. Ira Casson, who told a Congressional panel that there is not enough "valid, reliable or objective scientific evidence" showing that repeated blows to the head could cause permanent brain damage.
I'd argue that Casson — and his former friends at the NFL — could have saved themselves and the players a lot of trouble if they'd spent just a little time in the medical archives. That 1928 medical journal paper started a drumbeat of research into head injuries in athletes, continuing throughout the 20th century and intensifying in the past decade. The 82-year-old study, by Dr. Harrison Martland, remains frequently cited by researchers today, partly for its meticulous examination of damaged brains.
The paper is also a terrific reminder of early 20th-century medicine's down-to-earth approach to research. Martland, the chief medical examiner in Essex County, N.J., began his research by hanging out at boxing matches. He titled the paper "Punch Drunk," drawing on boxing cant. As he pointed out, boxing fans didn't hesitate to malign injured boxers, derisively shouting "cuckoo" when obviously brain-damaged fighters shambled into a ring, and referring to those with dementia problems as "slug nutty."
Martland did autopsies on more than 300 people who had died of head injuries, looking for patterns of brain damage. For his study of boxers, he talked a fight promoter into giving him a list of 23 former fighters he thought could be labeled as definitely punch drunk. Martland was able to track down only 10 of the former athletes, but in those cases, he found the promoter's diagnosis was on target. Four were in asylums, suffering from dementia. Two had difficulty forming sentences or responding to questions. One was almost blind, two had trouble walking and one had developed symptoms similar to those of Parkinson's disease.
His colleagues had also begun to realize that a concussive blow to the head could result in injuries that were remarkably slow to heal. An earlier study of repeated concussive blows in more than 100 people warned of possible mental degeneration: "It is no longer possible to say that concussion is essentially a transient state which does not comprise any evidence of structural cerebral injury."
Martland argued that blows to the head — and the inevitable shaking of the brain that resulted — caused small but cumulative hemorrhages that could lead to scarring called gliosis. Such fibrous scarring is now known to be associated with dementias like Alzheimer's and diseases like Parkinson's that affect motor control.
Surveys done in the past few years have found that NFL players are at higher risk of dementias and other mental disorders than the general population. Autopsies of athletes — notably the brains of former NFL players who suffered from profound dementias — consistently found dark clusters of nerve cell proteins, formations more common to elderly Alzheimer's patients. Similar patterns of damage were recently reported in wrestlers and soccer players. Most of these athletes were dead by age 50.
Doctors investigating these injuries have become effective advocates for player protection in the past few years, and their research has played a critical role in forcing a re-evaluation of game safety standards. At a Congressional hearing on football brain injuries, held in Houston on Monday, legislators accused college athletic officials of ignoring risks and failing to adopt polices that sufficiently protected young players. "It's money, money, money," said Rep. Steve Cohen, a Tennessee Democrat, "and health care ought to be considered."
The best response to such statements is: about time. As Harrison Martland's work reminds us, we can't pretend that we've just discovered that head blows pose a dementia risk. We can take credit for confronting the problem, albeit belatedly. And we can legitimately lay some blame here — if our response has been slow, that's mostly because the NFL, the National Collegiate Athletic Association and their allies have done an outstanding job, up until now, of ignoring and dismissing the medical record. Not everyone is happy about this, of course. Rep. Ted Poe, a Texas Republican, complained that "football as we know it" could be destroyed if we move toward greater protectiveness.
I feel safe in diagnosing that comment as slug nutty.