Hit Hard the Danger of Head Trauma Reading Plus

Am J Public Health. 2022 May; 104(5): 822–833.

The Commencement Concussion Crisis: Head Injury and Evidence in Early on American Football

Accepted Dec 8, 2013.

Abstract

In the early 21st century, sports concussion has become a prominent public wellness problem, popularly labeled "The Concussion Crisis." Football-related concussion contributes much of the epidemiological burden and inspires much of the public awareness. Though often cast as a contempo phenomenon, the crunch in fact began more than than a century ago, equally concussions were identified among footballers in the game's starting time decades. This early concussion crisis subsided—allowing the trouble to proliferate—considering work was washed by football game'south supporters to reshape public acceptance of risk. They appealed to an American civilization that permitted violence, shifted attending to reforms addressing more visible injuries, and legitimized football within morally reputable institutions. Meanwhile, irresolute demands on the medical profession made practitioners reluctant to take a definitive opinion. Drawing on scientific journals, public newspapers, and personal letters of players and coaches, this history of the early crunch raises critical questions about solutions being negotiated at nowadays.

On the previous folio: Head to head in an early Harvard football game game (ca. 1906-1912). Printed with permission, Harvard University Archives, HUPSF Football (209).

"The but serious injury I received was in the game with Harvard in 1883," typed sometime Penn footballer William Harvey in 1894, "when in a scrimmage backside the goal I was knocked insensible, just recovered in about xv minutes."1

Football was new, the Ivy League was its powerhouse, and the brutality of the game had recently brought its prohibition on more than than ane college campus. In response to the tensions, a committee of football game advocates had circulated a poll among former coaches and players about the game's safety and appeal. Harvey'southward letter was one reply. "During the summer following," it continued, "I was sick with blood gathering in the head and threatened with congestion of the encephalon, my illness being attributed by the Doctors to the in a higher place incident."i

Harvey had returned to play the post-obit year, although, as he explained, "at that time I played under another proper noun on account of family objections." He hoped that contempo reforms would brand injuries like his a thing of the past. "Under nowadays rules," he posited, "it would be nigh impossible for an injury to happen to a player, such as I experienced in '83."1

Harvey'south hope that the problem of head injury in football game could be solved with technical reform is one shared past many now, more a century later, as a "concussion crunch" emerges in American sports. Referring to the trouble as a "silent epidemic" in a 2003 report to the The states Congress,two the Centers for Disease Control and Prevention (CDC) estimated in 2006 that 1.6 to 3.8 million concussions occur annually in sports and recreational activities, amidst which football is the greatest contributor.iii One report of CDC data collected in 2005–2006 estimated that 55 007 concussions occur each year in organized high-schoolhouse football lonely.4 Some other calculated the concussion charge per unit during participation in football practice and contest to be 0.47 in high-school football game and 0.61 at the collegiate level. The rates approximately doubled when concussion rates were calculated for competition time only.5 Estimates vary, reflecting the challenge concussion presents to reporting and diagnosis, just information technology is articulate in the current concussion crisis that head injury is non just a problem of adults. This recognition, that concussion occurs at all levels of football, from Popular Warner to professional, has been important in the rising activism and increased reporting of caput injury over the past decade, as have claims that concussion in children is more severe, with longer recovery fourth dimension.half-dozen As sensation of the prevalence of concussion across the population swells, debates nigh its long-term health consequences have grown powerful.

The concussion crisis is unremarkably framed as a battle over testify and a need for new technical solutions. Some loftier-profile reports charge corporate interest groups of playing downward data most brain injury in former players, and others claim public health interest groups are playing it up.7 Corporation and player advocacy groups alike support epidemiological investigations of the link betwixt concussion and a degenerative encephalon condition called chronic traumatic encephalopathy,8 and both have partnered with prestigious medical institutions to report prevention, diagnosis, and handling.ix

Contrary to popular opinion, concussions are non a recent discovery in football, and this recent upwelling is not the first coming of the concussion crisis in American sports. It emerged more than a century agone, in the very first decades of football game. At that time at that place was aplenty evidence that concussion occurred often, and ample reason to believe that concussion could have long-term pathogenic consequences. When this early on crisis grew quiet, it was non considering concussions had been eradicated, fixed, or proven harmless. Technical reforms, past some measures, had actually made the concussion problem worse. The early concussion crisis subsided because concerted work was done by football'due south supporters to shape and reshape public credence of gamble: to appeal to an American culture that permitted violence, to shift attention to reforms that addressed more visible and immediate injuries, and to legitimize football within morally reputable institutions. Meanwhile, changing demands on the profession of medicine regarding what kinds of evidence constituted practiced medical exercise left early 20th-century physicians reluctant to have a uniform and definitive stance.

This early concussion crisis in football raises critical questions about what kind of solutions and settlements are existence negotiated in the electric current crunch and what risks, burdens, and inequities they will leave permissible. And the trouble in football, which now extends across youth, high-school, collegiate, and professional populations, is only part of the larger problem of head injury in sports today. What gained attention a century ago as a medical problem amid immature men playing football in elite colleges is now a serious problem of public health.

AMERICA'Due south MOST DANGEROUS PASTIME

Years before the first medical study of football game injury was published, it was obvious that this new American game was dangerous. Public and players alike had known that for decades; they had known it from the game'southward very beginnings, as a hybrid of English rugby and soccer evolved into a new form of football played among a number of elite American colleges. Newspapers reported bold headlines: "A Student Killed at Football,"10 "Dead From Football Injuries,"11 "More Slugging Than Playing."12 Reveling in hyperbole, 1 written report exclaimed in 1894 that "an ordinary rebellion in the South American or Central American states is as child's play compared with the destructiveness of a mean solar day's game."13 More affair of fact, another commented that "information technology behooves the promoters of the game to agree a conference and adopt some measures with a view of eliminating the dangerous plays in the growing sport."14 The tone varied from paper to paper, city to metropolis, but the message was articulate. "The nowadays Rugby game of football every bit played in this country is a very risky pastime," The New York Times proclaimed, conveying "well-nigh the aforementioned adventure that a soldier [assumes] on the battle field."15

In these early days, higher teams standardized rules gradually. 11 men to a side, they started plays with a crowded rugby scrum, forbade forward passing, and ran momentum plays like the infamous "flying wedge," resulting in gruesome injuries when the wall of running players crashed onto their target opponent. In that location was no padding, and on the head most wore simply a stocking cap for ornamentation and team identification.

Football game was i among many team games that emerged in the years post-obit the Civil War. Historiographical explanations for the new appeal of recreational sports in Reconstruction America have ranged widely, from a restless American spirit's need for a new outlet in one case the frontier was lost, to a compulsion to simulate wars looming on past or time to come horizons. Others argue that American sports emerged from a craving for customs in the ever-growing city of strangers, or a deep social anxiety almost health and fitness that came with changing demographic patterns at the end of the 19th century.xvi The reason given at the fourth dimension was stated as though it were as obvious equally the injuries. "The bold students," papers read, "risk life and limb to gain football honors for their colleges."17 The "triumphant football eleven" would render to their schools "covered with honors and blackness and blue bruises."eighteen What set football apart from other team games was that violence and bodily run a risk were constitutional in the appeal of the game.

In response, some colleges banned football game outright. The Harvard faculty intervened twice—in 1885 and once again in 1895—in calorie-free of its violent nature.19 Charles Eliot, president of the academy, led the opposition. "Worse grooming for the real struggles and contests of life can hardly be imagined," he wrote in his Annual Report of 1905. "Many serious injuries occur which are evidently recovered from in proficient measure, but which are likely to prove a handicap to the victim in later on life." Across the physical threats, he believed that "the master objection lies confronting its moral quality. . . . The common justification offered for these hateful weather is that football game is a fight and that its strategy and ethics are those of war" in which "the weaker man is considered the legitimate casualty of the stronger." His stance was unequivocal:

If a college or academy is primarily a place for preparation men for honorable, generous, and efficient service to the community at big, there ought non to exist more than one opinion on the question whether a game, played nether the actual weather condition of football, and with the fell ideals of warfare, can be a useful element in the grooming of young men for such service.20

Others were hopeful that reform would end the unsightly risks. The New York Times captured this sentiment, writing "1 thing is certain, and that is that our popular college sport must exist modified so every bit to permit of playing without danger of life and limb."21 In the Boston Globe, a footballer stated that he did "non call up the objections that have been raised to football are strong plenty to lead to its abolition as a college game. There are some things radically wrong well-nigh it, but we can correct them."22

Over the concluding decades of the 19th century, an intercollegiate rules committee was formed to revise and standardize the rules of the game. The committee comprised representatives from the diverse competing college teams, and was heavily influenced by the leadership of Walter Camp, known in his time as the "father of football" for his key contributions to game rules and advocacy for the sport. Camp and the commission fix to work saving the game through persuasive selection of evidence, technical reform, and pressure level on college administrators and faculty.23

In ane try, mentioned at the beginning of this article, they mailed out questionnaires to players, coaches, and other aficionados, collecting "skillful" opinions well-nigh the place of the game in American athletics.24 This is the questionnaire William Harvey was responding to when he detailed his "only serious injury" that had him "knocked insensible" and "ill with blood gathering in the head." Military camp compiled the many responses into a glowing 1894 volume on Football Facts and Figures that circulated widely, cited for decades as reliable evidence supporting the continuation of the game through controversy and reform.25

Harvey's response was included in Football Facts and Figures, but only in part. On his original letter, preserved in Camp's papers at Yale University, Harvey's description of his caput injury has been blatantly crossed out in crayon. In the published Football game Facts and Figures, Harvey'southward remaining testimony reads only this:

Philadelphia, April xx, 1894

I consider football one of the grandest games that is played. My experience on the football field has stood me in adept stead and has taught me self-possession and the faculty of deciding quickly and accurately. I believe that in many ways information technology fits a homo for the business of life when he comes in contact with his fellow men.

I have been out of college for nine years only I endeavor, at every opportunity to see a adept game of football.

Yours very truly, Westward. South. Harvey26

Harvey's message had been edited drastically, removing any trace of the reported head injury.

As evidence like this was selectively silenced and circulate in the interest of the game, a serial of dominion reforms was being tested on the field. The legalization of the frontward laissez passer was i. New possession rules and the creation of the quarterback position were others.27 These rule changes opened up the game, making fouls more than visible to referees and reducing momentum plays. They besides fabricated the game more interesting for spectators to sentry.

The watchdogs of player safety were not impressed with the outcomes of the dominion reforms. "The new rules," wrote one, "which were expected to attain so much in reducing the record of injury to players, failed entirely of their purpose."28 The response to the failings of the commencement reforms was more reforms, while the game grew e'er more entertaining.29

American football helmets have evolved over fourth dimension while the problem of concussion persists. Printed with permission, Smithsonian Institution Collections, National Museum of American History, Behring Center.

THE CONCUSSION CRISIS BEGINS

As feet mounted over the death of a student from head injury in 1906,30 the Harvard College team doctors released a damning and unambiguous study on "The Concrete Attribute of American Football" in the Boston Medical and Surgical Journal (BMSJ), printed on page one.31 Dismissing ongoing tinkering with reforms, the doctors came down "entirely against the game from its medical standpoint." Their article, systematically documenting the nature and number of injuries sustained past the team over the 1905 season, highlighted i injury in particular that had been hiding in plain sight: concussion of the encephalon.

The concept of encephalon concussion had been traveling through common and medical usage for centuries. As early as the mid-16th century it had been divers as a blow resulting in escape of blood from ruptured tissue. By the early 19th century it was described as an "external violence" that caused "derangement of the organization of the brain."32 Though, as the authors of the BMSJ written report noted, players were unlikely to acknowledge injury and tended to treat concussion as a joke, it was clear that "when a condition like this develops equally the result of an injury, the central nervous system has received a very severe shaking up." The doctors could not extrapolate from their modest, one-flavour sample to make strong claims about the long-term consequences of concussion, and neurologists had non studied football injuries in item, only those tasked with judging evidence for policy and practice took a stance. The American Medical Clan reported that, although

there was a fourth dimension when information technology was considered that convulsions and other untoward incidents of the unconscious life of the individual were not likely to be followed by serious consequences, this is not the stance at the present time.33

Head injury from other causes had provided testify of concussion's risks: railroad train collisions, frequent in the tardily 19th century, had generated a large study population for observing long-term effects of concussions of the brain and spine. Physicians said that the new frequency with which they were observing concussions fabricated the long-term behavioral consequences clinically visible—in children and adults.34

Both public and medical presses buzzed with the findings of the Harvard study. In 1 season alone at that place had been no less than nineteen concussions, and although some football advocates had guessed that only big games betwixt larger colleges had such high injury rates, the team doctors believed that "the number of injuries is inherent in the game itself, and is not due peculiarly to close competition in big games."35 The public received word of the doc's "astonishing statements with reference to the frequency and nature of the injuries sustained" from the popular printing, which noted that "the most surprising fact he states is with respect to encephalon concussions."36 The American Medical Association picked up on this extraordinary statistic, too, commenting that

peradventure the most serious characteristic of these accidents is the number of concussions of the brain reported. Only two games were played during the entire season in which a concussion of the brain did not occur.37

Newspapers had been noting concussions in headlines for more than than xx years, as the cause of death or hospitalization. The shock with the statistics of the 1906 paper was non that concussions were happening, just that they were happening in nearly every game without such obvious testify. According to the BMSJ written report, a concussion could occur without even the player himself realizing it. "The injury was frequently noticed by a surgeon from the side lines earlier it was recognized by the players," the authors explained. "A player might automatically run through a considerable series of plays before his fellows noticed that he was mentally irresponsible."38 Concussion was deemed something that could happen near invisibly in the dissonance and action of a game. The concussion crisis had begun.

VISIBLE ENOUGH TO COUNT

The plow of the century was a time of heightened awareness to injury. The industrializing workplace was a infinite where accidents inspired worker'due south compensation law, devastating factory fires alerted the public to a need for safety regulations, and the complexity of problems led to the formation of national councils to oversee them.

In this context, some physicians expressed frustration that their peers paid likewise trivial attention to head injuries. "Nosotros all know that whatsoever impairment of the brain seriously affects the entire economy," wrote one. "Why not give them that consideration their importance entitles them to?"39 He blamed "carelessness" in the treatment of even the almost obvious skull fracture for the "subsequent suffering" seen in victims of head injury. Treating observable injuries similar fractures with rest, symptom management, and reduction of stimulation might, he postulated, likewise intendance for invisible injuries in inaccessible parts of the brain:

Every case of recent caput injury, still trivial it may announced, should, we believe, exist treated with the greatest consideration, lest damage to subconscious and important structures escape our attention, thus leaving a foundation for future problem which likewise often is irreparable. . . . Unless our range of inquiry is sufficiently comprehensive to take in all possibilities, deeper injuries may remain, to exist followed past headache, epilepsy, or even insanity.40

But lack of medical attention was not only the result of carelessness. Around the same time that football was condign popular in American colleges, the profession of medicine was striving to proceeds new legitimacy as a scientific endeavor. Where clinical observation had once been sufficient proof of harm, a new demand was emerging for experimentally supported, show-based diagnoses and therapies. Physicians were increasingly expected to rely on technical diagnostics—visualization technologies that would give proof of the presence of a pathology—and experimental, statistical proof to dorsum their prescriptions.41 These kinds of scientific prove were exceedingly hard to extract from the occult regions of the encephalon and the hidden processes linking brain and behavior over time.

Physicians were all too enlightened of their disability to produce visual prove. Injury, they conceded, could occur in the encephalon without visible impairment to the head. But there were serious constraints to proving this in a living person. For injury hidden below skin and bone and inches of seemingly unaffected brain tissue, there was no easy means of detection, no "rational surgical process based on scientific discipline and common sense" every bit there was for fractures of the skull and visible tearing of the brain.42 New nerve staining techniques only immune for postmortem assessments and diagnoses.43 Roentgenogram imaging, the vanguard of x-ray technology at the time, could only visualize fractures of the skull, not trauma to soft tissue.44

Physicians recognized that limitations in imaging the brain were limiting their ability to scientifically empathise not only the injury itself, simply also long-term psychological furnishings. There was no agreed mechanism, no theoretical consensus, for how concussion injured the brain. Older doctors forwarded a mechanical theory that

cerebral concussion, past causing inflammation of the meninges which spread to the brain, disorder its apportionment and nutrition and thus produce psychic disease, at in one case or after a long interval.45

Others hypothesized that concussion inverse the brain'southward molecular composition. "With or without material injury," one wrote,

the stupor produced by the accident may cause molecular change in the brain, thereby producing psychic disturbances or a predisposition, especially in neurotic individuals . . . insanity may not occur until after a long interval, during which no special symptoms occur.46

But in the absence of imaging, the latent flow between traumatic injury and behavioral symptoms proved a bulwark to building an evidence-based theory. The mechanical theory was not

sustained past the facts found in many cases, for the reason that the surgeon and pathologist have failed to evidence a state of facts. If such lesions did be they would accept given recognizable symptoms (which actually accept been entirely absent) during the interval.47

And the molecular theory foundered on the conclusion that in that location was "no proof of any such molecular changes if they produced no recognizable weather condition."48

Every bit these theories faltered for lack of evidence, a unlike theory based on pathological findings was gaining support. Researchers had identified tiny capillary hemorrhages surrounded by softened brain tissue in heads known to take been concussed,

mostly located in the surface of the brain beneath the contused part, but frequently too deep downwards effectually the ventricles or in the portion of the brain diametrically opposite the injured portion.49

Others had linked these hemorrhages to behavioral change. "Not infrequently later injuries to the caput," one wrote, "a very decided modify is seen in the mental condition. . . . In at least some of the cases in that location are infinitesimal hemorrhages of minute areas of softening throughout the encephalon caused by trauma."50

Causal links between concussion, hemorrhaging, and behavioral changes were hard to substantiate. Although many suspected that concussion caused both insanity and alcoholism, this was difficult to bear witness when not everyone striking in the caput became drunkard or insane. Some thought head injury just acted every bit a mediator, exacerbating preexisting atmospheric condition and speeding up their grade. Others thought the head injury could only deed as a cause in people who were predisposed by hereditarily weak constitution. To command for competing ideas the researchers required that, to be counted as a example, a corpse must take been in good health before the concussion effect and that "the symptoms must be of singled-out evolution and must come on within a reasonable time."49 This limited what kinds of effects could be seen, counting out side furnishings or symptoms that did not nowadays until later on in life. And it made it even more than difficult to power a study specifically investigating concussion associated with football.

SHIFTING RISK TO THE Brain

New padding, new rules virtually mass tackles, and other game reforms began to reduce injuries to "life and limb," statistically improving morbidity and bloodshed reports on the kinds of injuries that could be measured.51 But, in doing so, reform shifted take a chance to the more than scientifically ambiguous areas of the brain and life exterior the football spotlight. "Football game Expressionless 14 With the New Rules," a newspaper announced to the public, its subhead elaborating "Fewer Fatalities and Bad Injuries Shown in 1910, but Numbers Are Nonetheless Large. Cases of Concussion of the Encephalon Increase." The article highlights a growing incidence of concussion:

Concussion of the brain was the leading cause for the deaths this twelvemonth, as has been the example in the past, simply it led past a much higher proportion than in either of the ii preceding years. Most of the accidents which caused this injury came from the open field tackles, while there was a decrease in the number of men hurt in the mass plays. The number of those who received blows on the head resulting in concussions which were non fatal also showed a large increase.52

This shift of chance to the encephalon continued even as medical regime wrote more and more confidently nigh the links between nonfatal concussion and mental disorder. By 1911 a Periodical of the American Medical Association (JAMA) article, summarizing the piece of work of a number of German psychiatrists globe-renowned for their neurologic enquiry, claimed that a constellation of mental disorders shared a "common etiologic factor, namely, trauma to the caput."53 Acknowledging that not every person who was hit in the head developed the aforementioned outcomes, it was distinguished that

injuries which produce an extensive, diffuse shaking upward or shattering of the brain tissue, such as occurs in concussions or those which produce extensive pressures on the brain, volition exist followed past mental disturbances.54

Their visual clarification of concussion reinforced the growing consensus effectually a mechanism of diffuse microscopic changes in the brain, characterized by minute hemorrhages and softenings, and their enquiry linked this physical alter to behavioral change. Concussion could "be followed by no untoward, firsthand symptoms," the article noted, standing:

The patient may not fifty-fifty lose consciousness, only walk to his home and manifestly non be the worse for the experience, until later—sometimes weeks and even months afterwards—he begins to show a very noticeable modify in his psychic total. His entire mental make-up changes, he becomes easily tired, is incapable of any prolonged mental effort, is forgetful, irritable and distractable. He complains of vertigo, pressure sensations in his caput, migraine, noises in the ears; he experiences a sort of general benumbed feeling and shows a marked tendency to outbreaks of violent temper on the to the lowest degree provocation.55

Although the classification of this psychosis was not entirely clear, the authors were certain that "those who knew the private before the injury volition invariably notice" the modify.56

The JAMA report concluded with a clear exhortation that the medical community treat concussions non but as acute injuries, but according to the "effects the injury will take on the patient's future life." These injuries had the potential to rob the "faculties which bring about an aligning between individual and environment," and if the injury was not fatal, "the question of paramount importance which and then comes upwardly is . . . one of a more than far-reaching importance, namely, 'How will the future life of the patient exist modified by this injury?'"57 The fact that there were instances in which there was liability law–induced malingering did not detract from the existent cases, and physicians were urged to take seriously "the importance of this course of mental disturbance for the general practitioner, and peculiarly for the practicing neurologist." It could

hardly be overestimated, particularly when we remember that according to Friedman'due south statistics, threescore per cent of all concussions to the brain are followed past psychic disturbances for a year or more than later on the injury, and that according to Ziehen, the traumatic psychoses form iii per cent of all admission to hospitals for the insane.57

On the basis of the neurologic literature and the series of cases, the report concluded that

caput injuries may have a lasting deleterious effect on the private that while a cross section at whatever particular point may non testify any gross pathologic findings, nonetheless a report of the entire private'southward life will reveal a decay of his finer functions of intellect, which stamps him as a chronic psychic invalid.58

By 1928, Harrison Martland of New Jersey had demonstrated the markers of traumatic encephalitis in the brains of "punch drunkard" boxers subsequently decease, showing that such injuries and effects could occur in sport.59 Only no studies were done on football until much subsequently in the century.

INCENTIVES TO Doubt

Football survived its starting time concussion crunch not because of lack of prove or considering the trouble was technically solved, merely because its promoters worked to make football's perceived contribution to social values greater than its risks. Certainly, there were fiscal stakes in football. The sport emerged in an era of unfettered betting among both players and spectators. One paper noted that, earlier a game in 1893, students stayed upward all night and "those youngsters bet as though the war was going on."60 Bankers on the flooring of the Stock Substitution in New York bet larger amounts among themselves, where one had "bet $500 that Princeton would not score, and said that he had $1500 more to wager on the same conditions."61 The financial stakes grew as the game became more popular. Colleges competing for students saw the value of having a squad in the popular sport, and the formation of the American Professional person Football Association in 1920 only deepened the incentive to proceed the game and ignore its inherent risks. Unlike the college teams, made up of elite youths playing an unpaid game, the professional league was a collection of men paid a salary. A past lack of attention to work-related injury in the industrial workplace did not bode well for football norms, which would shape and cement the norms of colleges and eventually high schools. Equally Harvard Athletic Director William Bingham wrote in 1935,

there has been pressure from the professionals, and I think I sense a tendency on the part of some colleges to eyebrow some of the things they decided to discard a one-half dozen years ago.62

Merely financial interests were not alone in sustaining the game. Football as well tapped a cultural penchant for strength and stimulation in a club tolerant of violence. In football game's early and uncertain days, boosters worked actively to align the rhetoric about football game with the culture of the time, to enmesh the game in the moral interests of the elite colleges, and to suppress evidence of the game'due south risks while promulgating evidence of the game'southward improvement. It appealed to anxieties almost America's relative lack of fitness, and appealed to a culture of manliness pervasive in the early on 20th century. Choosing to take on run a risk, demonstrating skill and loyalty—all of these were characteristics of the manly ideal.63 Reforms claimed to make the game more "scientific," highly-seasoned to a culture that believed that a game, if played "scientifically," could be played without danger.64 This illusion of a scientific and injury-free game survived even subsequently reforms repeatedly failed to remove the risk. Public claims were made that "expert players are less liable to injuries. . . . Playing to the betoken of exhaustion should be avoided. Proper padding besides prevents injuries."65

All the while, the rising incidence of concussion was apparently forgotten. Within the colleges of the time, there was a sense that their function was to not just brainwash in academics but also to plow boys into men. Although a few academy leaders argued that toughness could come from less-violent athletic activities, they were out-voiced by coaches and even powerful politicians lobbying for the special values of football.66 As Harvard's Bingham wrote, "no young human tin play football nether [Omnibus] Harlow without being a amend man when he is through. By this I do non mean physically but in every mode that makes for manhood."67 The manly quality of loyalty further masked the evidence of the dangers inherent in the sport. It meant not doing things that could harm the reputation of the squad, but information technology as well meant upholding the game. "We must take loyalty!" Motorbus Harlow wrote to the athletic director. "Football takes enough toll of ones brains and energy in the fall without the insidious cancer of disloyalty eating out the vitals of the system."68 This meant not continuing to feed news of injury to the public sphere through the newspapers and medical journals, with pressure coming not only within the university but likewise nationally. "Every bit I told you," a member of Wisconsin's Interscholastic Able-bodied Association wrote to Harvard's Dean Delmar Leighton in 1935,

I want no fellow member of the football game staff writing for the papers. I feel our task should swallow all of our time and brains and with no intended criticism of the by, I experience that a measure of dignity that is associated with the name of Harvard is lost in and then writing.69

Even members of the Rules Committee steered clear of the public in protection of the game. I important and well-respected commission fellow member, William Langford, became so upset at the internal handling of thespian safety that he resigned. "In that location is not the slightest incertitude in my mind that encouragement of the 'slow whistle' is a direct invitation to roughness and injury,"70 he wrote in confidence to the Harvard athletic manager. Merely instead of speaking out about the incongruity, he left quietly. "I accept purposely kept the matter repose because publicity of any sort would be harmful to the game," he confided in endmost.71

I of the slap-up conundrums of the manly ideal in football is that it came to require the participation of immature boys. In its early days, children had been excluded. "Football is not a sport for boys by whatsoever means, and young men ought to be strong in the commencement place and be bodacious of good coaching in the 2nd before they tackle it," 1 newspaper reported the common belief.72 Only within the side by side few decades, secondary schoolhouse principals were justifying the game and the serious injuries it entailed among their youths. When reports of injury in the high-school game became heated, Principal Chamberlain of Milwaukee's Riverside Loftier School wrote to Dean Delmar Leighton of Harvard College urging that the rules non exist changed to make the game safer. He counted his pupils among the "men who are playing football" and downplayed the accented number of injuries. The injury rate in high schools, he calculated, was only about one fifth of that in the colleges. Past this accounting, he concluded that made "high school football game a good bargain safer than that in college when we consider the number of players engaged."73 The prototype of the high-schoolhouse game was "as much to the involvement of colleges every bit it is to the loftier schools," he warned. "Should football game in secondary schools receive a black heart, then the game in the colleges volition certainly be afflicted."

In a higher place and Right: Images on the website of Riddell, the company that makes the "Official Helmet of the NFL," appeal to parents with the message that they tin can exist practiced parents by ensuring their children wearable helmets. Others on the site reinforce the cultural thought that putting immature children in warrior-similar scenes is natural and desirable.

FOR THE LOVE OF THE GAME

Reform of the game rules sustained a wistful hope that the game could be made acceptably safe through technical fixes, which came to include protective equipment for the torso also equally rule reform. But hope, and the limitations of research methods to detect unintended consequences, covered up an uneasy sense that the technical fixes were non solving the problems. "I retrieve nosotros should consider at our meeting this winter the whole question of the nowadays equipment," said Walter Okeson, Commissioner of the Eastern Intercollegiate Association, in 1935. "I sometimes wonder if some of the equipment is non causing as many injuries as events."74 The comment was raised by a question Bingham had posed to members of the rules committee that yr. "In connection with equipment," he said, "I am wondering if the Rules Committee will make any recommendation adjacent yr with regard to the thigh pads and other pads which have made necessary a heavier headgear."75 Stronger and heavier padding for the body posed greater risk to the head.

In response, leather headgear evolved to plastic helmets, starting time required among higher footballers in 1939. The plastic football helmet was amended to include a face mask in 1956. Through the 1960s plastics were improved and so that the helmets no longer shattered as easily as the initial incarnations. Early business concern focused on preventing skull fracture more than concussion,76 but growing interest in injury prevention eventually brought greater attention to injury to the caput and spine more more often than not. In the early on 1970s air bladders were added to "energy-absorbing helmets" and four-signal chin straps were required at the collegiate level afterwards 1976.

Over the next two decades scientific and media attention around concussions in professional football grew. By the mid-1990s concussions were making the news again. The New York Times reported just earlier the 1994 Super Bowl that star quarterback Troy "Aikman's concussion has focused attending on a dangerous and recurring injury in the National Football League."77 Through these decades, new regulations, new brain imaging technologies, and attention to youth sports injury were significant in the re-emergence of the crisis.78 Past 2002, Riddell Sports produced a new official helmet blueprint for the National Football League (NFL) that was primarily "intended to reduce concussion," co-ordinate to the league's Web site.79

Although loftier-end helmet design over the past century has led improvements in protection, helmets take regrettably non solved the public health problem. Information technology is an indication of the intractability of this problem that, past 2011, the new helmet offerings were not solutions, merely rather "impact indicator" chin straps, collecting data on the concussive blows that persisted despite walls of air, plastic, and skilled blueprint.

Neither have solutions been institute in clinical treatment of concussion, which has not advanced much beyond rest, reduction of sensory stimulation, and symptom management—like recommendations to those available in the early decades of the 20th century when the crunch was first documented. Research and response have accelerated. Findings on the compounded risk of multiple head injuries have influenced official recommendations nearly return-to-play decisions.80 Most states have passed legislation requiring education, removal of a concussed athlete from the game, and medico clearance earlier returning to play.81

And however, through ongoing tinkering with equipment and reforms, much continues to exist ignored, rationalized, and delayed for the love of the game. In 2010, for example, in response to strong advocacy and evidence of the immediate and long-term risks of concussion, the NFL required all teams to hang posters in team locker rooms that detailed the risks of concussion.82 When the tobacco industry began labeling cigarette packages with Surgeon General'south warnings about the risks inherent in tobacco smoking, some saw this as a success for public health besides. With fourth dimension, however, the legal loophole that this label created for the tobacco corporations became apparent. Once the users had been warned that the product was dangerous, the risk became their own and non the responsibleness of the visitor or the public who permitted the product to be sold.83 The NFL's labeling of locker rooms with posters too individualizes responsibility, institutionalizing the thought that it is the player's responsibility to recognize and assume the risk of concussion. Current National Collegiate Able-bodied Association guidelines, too, expect student athletes to self-report signs and symptoms of concussion to their medical staff.84

This expectation is contraindicated not simply past the visual quietness of serious caput injury in the loud frenzy of a game, just also past an honest evaluation of the stakes and power differentials in the decision, which asks people to decide whether to make this career- and squad-changing decision in the confront of a multibillion dollar networked corporation and a culture of loyalty and forcefulness that is notoriously tolerant of violence. And it neglects the reality that adult football game players start every bit children, and that the construction of the professional person corporation depends on these children coming upwards through the ranks—not only the few children who will e'er play professionally simply besides all the children who never volition. All are subjected to known risks, with the approval of their watching friends, parents, and teachers.

Terminate ZONE

Better ways of reducing the risks of caput injury may be found through high-contour collaborations of medical scientific discipline and football corporations. But the long history of the concussion crisis tells united states that, although the pursuit of fixes is well and good, proponents of fixes demand to know their enemies: the financial interests that support the status quo, and the cultural assumptions linking football, violence, and our current iterations of manliness.85 Steps must be taken to ensure that safety and honest interpretations of scientific discipline bulldoze the research that is done and the conclusions that are reached.

The ultimate challenge to building and implementing good policy may be that football became popular not despite its violent aspects, only because of them. The most constructive interventions will surely be integrative of improved technical protections, regulatory modifications, enforcement of rules and policies, and public pedagogy, as well as diagnostics and treatment of the injuries that will continue to occur. But the mass popularity of unsafe sports inhibits the interventions that might be nigh effective at all levels—from youth to collegiate to professional. The inherent dangers of the game volition continue under the cloak of budgetary settlements similar that announced in Baronial 2013.86

This was acknowledged among even the very primeval discussions near American football's concussion crunch. "An endeavor has been made to gloss over football's worst aspects past widely published suggestions that no game is entirely without the danger of expiry under accidental circumstances," JAMA reported in 1906. But the injuries are "absolutely dependent on the present methods of playing the game itself, and bound to occur." The fact that so many injuries

occur in one season of play is of itself enough to stamp on the game as something that must be greatly modified or abandoned if nosotros are to be considered a civilized people, and if our universities are to be considered centers for influence for skillful.

The realities of the game should be its death knell, the writers argued, unless government "fearfulness unpopularity more than than they cartel to be right."87

Acknowledgments

Thank yous to Allan Brandt and David Jones for conscientious reading and communication. I am grateful also to Charles Rosenberg for discussions on an early on typhoon and to the reviewers for their helpful comments.

Human Participant Protection

Institutional review lath approval was not required as this study did not involve man participants.

Endnotes

1. Walter Chauncey Camp Papers (MS 125). Manuscripts and Archives, Yale University Library.

two. National Heart for Injury Prevention and Control, Report to Congress on Mild Traumatic Brain Injury in the The states: Steps to Prevent a Serious Public Wellness Problem (Atlanta, GA: Centers for Illness Control and Prevention, 2003).

3. J. A. Langlois, Westward. Rutland-Brownish, and G. M. Wald, "The Epidemiology and Affect of TBI: A Cursory Overview," The Journal of Head Trauma Rehabilitation 21, no. 5 (2006): 375–378. [PubMed]

4. Centers for Affliction Command and Prevention, "Sports-Related Injuries Among High Schoolhouse Athletes—U.s.a. 2005–06 School Year," Morbidity and Mortality Weekly Report 55, no. 38 (2006): 1037–1040; P. R. Shankar et al., "Epidemiology of High School and Collegiate Football game Injuries in the United States 2005–2006," The American Journal of Sports Medicine, no. eight (2007): 1295–1303.

five. 50. M. Gessel et al., "Concussions Among US High School and Collegiate Athletes," Journal of Athletic Training 42, no. 4 (2007): 495–503. Rates are calculated per one thousand athlete-exposures, i.east., for every thousand participations in a practice or a competition.

6. P. McCrory et al., "Consensus Statement on Concussion in Sport—the tertiary International Conference on Concussion in Sport, Held in Zurich, November 2008," Journal of Clinical Neuroscience 16, no. 6 (2009):755–763; Centers for Illness Control and Prevention, "Nonfatal Traumatic Brain Injuries Related to Sports and Recreation Activities Amidst Persons Aged ≤19 Years—Us, 2001–2009," Morbidity and Mortality Weekly Report 60, no. 39 (2011): 1337–1342.

vii. For case: Alan Schwartz, "Concussion Committee Breaks With its Predecessor," New York Times, June 1, 2010: B12.

8. B. E. Gavett, R. A. Stern, and A. C. McKee, "Chronic Traumatic Encephalopathy: A Potential Belatedly Effect of Sport-Related Concussive and Subconcussive Head Trauma," Clinics in Sports Medicine 30, no. 1 (2011): 179–188. See besides the Sports Legacy Institute Web site at: http://www.sportslegacy.org. [PMC costless commodity] [PubMed]

9. The National Football League Players Clan has granted Harvard Medical Schoolhouse $100 million for a 10-year initiative to practice simply this: D. Cameron, "HMS Partners With NFL Players Association," Harvard Gazette, January 29, 2013, http://news.harvard.edu/gazette/story/2013/01/nflpa_hms_initiativ (accessed February 5, 2014)

10. "A Student Killed at Football," New York Times, October 22, 1887.

11. "Dead From Football Injuries," New York Times, November 13, 1903, News sec.

12. "SISS-BOOM-AH, More Slugging Than Playing," Boston Daily Earth, November 13, 1887: 4.

13. "Yale Again Triumphant," New York Times, November 25, 1894, News sec.

14. "Change the Football Rules: The Rugby Game every bit Played Now Is a Dangerous Pastime," New York Times, December two, 1893, News sec.

xv. Ibid.

16. Foster Rhea Dulles, A History of Recreation: America Learns To Play (New York: Appleton-Century-Crofts, 1965); Clifford Putney, Muscular Christianity: Manhood and Sports in Protestant America, 1880–1920 (Cambridge, MA: Harvard Academy Press, 2001)

17. "Ready for the Nifty Struggle," New York Times, November 30, 1893.

18. "Harvard Forfeits: Championship Game to Yale Kickers," Boston Daily Globe, November 26, 1888: 5.

19. Harvard University, Annual Reports of the President and Treasurer of Harvard College, 1894–1895, http://pds.lib.harvard.edu/pds/view/2574409?n=3226 (accessed July 25, 2013): "The evils of football at present became so bang-up that the Kinesthesia, in January 1885, prohibited all intercollegiate football games. This prohibition was maintained for one year. In the bound of 1895, the Faculty adopted a vote (Feb nineteen) 'that the Faculty desire the Committee to put a stop to all intercollegiate foot-ball contests.' . . . On the 19th of March, the Faculty adopted the following vote: 'The Kinesthesia, having received and considered a advice from the Committee on the Regulation of Athletic Sports, dated February 25, 1895, remain of the stance that no student under their charge should be permitted to accept part in intercollegiate pes-ball contests'; but on the 7th of May, a resolution 'that the Kinesthesia of Arts and Sciences will not permit a student under their charge to take part in any intercollegiate foot-brawl contest' was lost by a decisive vote.".

20. From President Eliot's Annual Study for 1903–4: 18–22. Records of the President of Harvard Academy Charles William Eliot. Pusey Archives, Harvard Academy. Box 220/164.

21. "Alter the Football game Rules," New York Times.

22. Editorial, Boston Earth, February 3, 1905. The same editorial reported another footballer saying that Eliot "certainly striking things pretty virtually correct. I didn't realize the president knew and then much about the game. At that place is no getting around his argument on the morality of the game, but it would non take much to right them. If we had some officials who had the courage to enforce the rules, and enforce them to the limit, the trouble would exist solved.".

23. Run into, for example, messages nerveless in Records of the President of Harvard University Charles William Eliot, Pusey Archives, Harvard Academy, Box 87 (binder Football, 1906)

24. Walter Chauncey Military camp Papers (MS 125), Manuscripts and Archives, Yale University Library.

25. A. Ronald, Smith, Sports and Freedom: The Rise of Big Time College Athletics (New York, NY: Oxford Academy Press, 1988)

26. Walter Army camp, editor, Football Facts and Figures: A Symposium of Practiced Stance on the Game's Place in American Athletics (New York, NY: Harper and Brothers Publishers, 1894): 167–168.

27. "Changes in Football game," The Harvard Scarlet 48, no. 82 (1906); see as well John J. Miller, The Big Scrum: How Teddy Roosevelt Saved Higher Football game (New York, NY: Harper Collins, 2011). N.B. The facts are useful, but the tone of this volume is an exhibit of the macho attitude critiqued in this commodity, and not my analysis of the history.

28. "Yale Again Triumphant," New York Times.

29. In a letter of the alphabet during the autumn of 1905, Harvard'southward President Eliot noted the significance of the shift. "My own opinion is that intercollegiate football game ought to be forbidden to Harvard students," he wrote. "But I practise not know that the Governing Boards of the University are now gear up for that footstep. There has undoubtedly been a great change of public stance well-nigh the value of football within the last two years." (Letter of the alphabet from Eliot to Mr. A. Thousand. Foerster, Nov 23, 1905, Records of the President of Harvard Academy Charles William Eliot, Pusey Archives, Harvard Academy, Box 194 [folder, Intercollegiate Football 1905])

xxx. Miller, The Big Scrum.

31. E. H. Nichols and H.B. Smith, "The Physical Aspect of American Football game," Boston Medical and Surgical Periodical (1906):ane.

33. "Surgical Aspects of Football," Journal of the American Medical Association 46, no. 2 (1906): 123.

34. "The Railway Spine," Railway Times 18 (November 24, 1866)

35. "Surgical Aspects of Football": 123.

36. Harvard Plans Reform of Football game Rules," New York Times, Jan 6, 1906; "Injuries in Football game at Harvard," Boston Daily Globe, January v, 1906.

37. "Surgical Aspects of Football game": 123.

38. Nichols and Smith, "The Physical Aspect of American Football": three.

39. W. H. Earles, "Necessity for More Care in the Handling of Skull Fractures," Journal of the American Medical Association 41, no. 3 (1903): 170.

twoscore. Ibid., 169.

41. For more on this shift meet Harry Marks, The Progress of Experiment: Science and Therapeutic Reform in the United States, 1900–1990 (Cambridge, MA: Cambridge University Press, 1997), which is full of references to seminal works on the topic including C. E. Rosenberg and Thousand. J. Vogel, eds., The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia, PA: University of Pennsylvania Press, 1979); J. H. Warner, "Ideals of Science and Their Discontents in Belatedly Nineteenth-Century American Medicine," Isis 82 (September 1991); A. Cunningham and P. Williams, editors, The Laboratory Revolution in Medicine (Cambridge, MA: Cambridge Academy Press, 1992). See besides J. D. Howell, Engineering in the Hospital: Transforming Patient Intendance in the Early Twentieth Century (Baltimore, Physician: Johns Hopkins University Printing, 1995) and D. S. Jones, Cleaved Hearts: The Tangled History of Cardiac Care (Baltimore, Physician: Johns Hopkins University Press, 2012) for discussion of visualization technologies in medicine.

42. Earles, "Necessity for More than Intendance in the Handling of Skull Fractures":169.

43. "Tumors of the Brain," Journal of the American Medical Association 20, no. 6 (1893): 162–163.

44. J. W. Stewart, "Fractures of the Skull: Diagnostic and Prognostic Features," Periodical of the American Medical Association 77, no. 26 (1921): 2030–2035.

45. A. C. Brush, "A Study of the Traumatic Insanities," Periodical of the American Medical Association 53, no. xiv (1909): 1081–1084.

46. Ibid., 1081.

47. Ibid.

48. Ibid.

49. "The Remote Effects of Head Injuries," Periodical of the American Medical Association 42, no. 6 (1904): 380.

50. C. W. Burr, "Trauma of the Head every bit a Cause of Insanity," Journal of the American Medical Clan 48, no. 1 (1907): 33–37.

51. E. H. Nichols and F. L. Richardson, "Football Injuries of the Harvard Squad for 3 Years Under the Revised Rules," Boston Medical and Surgical Journal (1909): lx. [PubMed]

52. "Football game Dead fourteen With the New Rules," New York Times, November twenty, 1910.

53. B. Glueck, "Traumatic Psychoses and Post-Traumatic Psychopathic States," Journal of the American Medical Association 56, no. xiii (1911): 943–948.

54. Ibid., 945.

55. Ibid., 944.

56. Ibid., 945.

57. Ibid., 947.

58. Ibid., 948.

59. Harrison Due south. Martland, "Punch Drunk," Journal of the American Medical Association 91, no. 15 (1928): 1103.

60. "Set up for the Great Struggle," New York Times, November 30, 1893.

61. Ibid.

62. William Bingham, Letter to Wm Langford, 11 November 1935, Harvard Athletic Association Archive, box 8, binder "Football game Rules Committee 1935-8," Harvard University Archives.

63. See, for example, H. C. Mansfield, Manliness (New Oasis: Yale University Press, 2006); G. Bederman, Manliness and Civilization: A Cultural History of Gender and Race in the Us, 1880–1917 (Chicago, IL: University of Chicago Printing, 1995); James R. McGovern, "David Graham Phillips and the Virility Impulse of the Progressives," The New England Quarterly 39 (1966): 335.

64. "A Football Thespian'southward Fatal Hurt," New York Times, October 22, 1892.

65. "Football at Harvard," New York Times, March 7, 1909.

66. Harvard'south President Eliot, for example, thought rowing would inculcate the kinds of toughness best suited to a life of business organization and other professions. Annual Study 1903–four:18–22. Records of the President of Harvard Academy Charles William Eliot. Box 220/164. The concluding line is moving: "Civilisation has been long in possession of much higher ethics than those of war, and experience has abundantly proved that the highest efficiency for service and the finest sort of backbone in private men may be accompanied by, and indeed bound from, unvarying generosity, gentleness, and good will.".

67. L. D. Worsham, Manager of Athletics, Ground forces Able-bodied Association, W Betoken. Letter of the alphabet to William J. Bingham, Director of Athletics, Harvard, seven January 1935, Harvard Athletic Clan Archive, box seven, folder "Richard Harlow 1935," Harvard University Athenaeum.

68. Richard C. Harlow, Letter to William Bingham, 21 January 1935, Harvard Athletic Clan Annal, box 7, folder "Richard Harlow 1935," Harvard Academy Archives.

69. G. A. Chamberlain, Lath of Control Wisconsin Interscholastic Athletic Association, Milwaukee, Letter to Dean Delmar Leighton, 9 Academy Hall Cambridge. 3 Dec 1935. Harvard Athletic Association Archive, box viii, binder "Football Rules Commission 1935–8," Harvard University Athenaeum. Chamberlain wrote to the Rules Commission to foreclose reform of the high-school game rules, maxim that "for the good of the game I am of the stance that reports which are sent out from some quarters in the East should be strenuously discouraged.".

70. A "slow whistle" refers to a referee'due south await to blow the whistle at a rule infringement until the infringement meets a cut-off threshold. For example, if a player was tackled the whistle would not be blown until he was completely immobilized; otherwise he could get upwardly and run again.

71. William Langford, New York, Letter to Wm Bingham, 12 November 1935, Harvard Athletic Association Archive, box 8, binder "Football Rules Commission 1935–8," Harvard Academy Athenaeum.

72. A Football Player's Fatal Hurt," New York Times, October 22, 1892.

73. Ibid.

74. Walter Okeson, Commissioner Eastern Intercollegiate Association, Letter to Wm Bingham, 24 October 1935, Harvard Able-bodied Association Annal, box 8, binder " Football Rules Committee 1935–8," Harvard University Archives.

75. William Bingham, Alphabetic character to Walter Okeson, 22 October 1935, Harvard Athletic Association Archive, box 8, folder "Football Rules Committee 1935–8," Harvard University Archives.

76. See, e.g., John Sayle Watterson, College Football: History, Spectacle, Controversy (Baltimore: Johns Hopkins Academy Press, 2002); John S. Watterson, "Inventing Modernistic Football" American Heritage Magazine 39 (1988): 102.

78. Run into, for case, S. G. Gerberich et al., "Concussion Incidences and Severity in Secondary School Varsity Football game Players," American Journal of Public Health 73, no. 12 (December 1983): 1370; F. O. Mueller and R. C. Cantu, Nineteenth Annual Report of the National Center for Catastrophic Sports Injury Enquiry: Fall 1982–Bound 2001 (Chapel Colina, NC: National Center for Catastrophic Sports Injury Inquiry, 2002)

80. Grand. M. Guskiewicz et al., "Cumulative Furnishings Associated With Recurrent Concussion in Collegiate Football Players: The NCAA Concussion Written report," Journal of the American Medical Association 290, no. 19 (2003): 2549–2555; McCrory et al., "Consensus Statement on Concussion in Sport.". [PubMed]

81. Centers for Affliction Command and Prevention, "Injury Prevention and Control: Traumatic Brain Injury," http://world wide web.cdc.gov/concussion/policies.html (accessed September ane, 2013)

82. See, for example, "Affiche Warns Players on Concussions," The Associated Press via ESPN (July 27, 2010), http://sports.espn.go.com/nfl/news/story?id=5412862 (accessed April ane, 2010); Steven DeKosky, Milos Ikonomovic, and Sam Gandy. "Traumatic Brain Injury—Football, Warfare, and Long-Term Effects," The New England Periodical of Medicine 363, no. xiv (2010): 1293–1296.

83. Allan M. Brandt, The Cigarette Century: The Ascent, Fall, and Deadly Persistence of the Production That Divers America (New York, NY: Bones Books, 2009)

84. 2012–xiii NCAA Sports Medicine Handbook, vol. 56 (Indianapolis: National Collegiate Able-bodied Association, 2012)

86. Ken Belson, "NFL Agrees to Settle Concussion Suit for $765 Million," New York Times, August 29, 2013, http://www.nytimes.com/2013/08/30/sports/football game/approximate-announces-settlement-in-nfl-concussion-suit.html?_r=0 (accessed September one, 2013); Gary Mihoces, "NFL Reaches Concussion Settlement," United states Today, August 29, 2013, http://www.usatoday.com/story/sports/nfl/2013/08/29/nfl-concussion-settlement-gauge-anita-brody-tony-dorsett-jim-mcmahon-junior-seau/2727483 (accessed September ane, 2013)

87. "Surgical Aspects of Football": 123.

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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987576/

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