When Can I Drive Again After a Traumatic Brain Injury Usa
Am J Public Health. 2014 May; 104(5): 822–833.
The First Concussion Crisis: Head Injury and Testify in Early on American Football game
Accepted December 8, 2013.
Abstract
In the early 21st century, sports concussion has go a prominent public wellness problem, popularly labeled "The Concussion Crisis." Football game-related concussion contributes much of the epidemiological burden and inspires much of the public awareness. Though often cast as a recent miracle, the crisis in fact began more than a century ago, as concussions were identified among footballers in the game's get-go decades. This early concussion crunch subsided—allowing the trouble to proliferate—considering work was washed by football game'southward supporters to reshape public acceptance of risk. They appealed to an American civilisation that permitted violence, shifted attention to reforms addressing more visible injuries, and legitimized football inside morally reputable institutions. Meanwhile, changing demands on the medical profession made practitioners reluctant to take a definitive stance. Cartoon on scientific journals, public newspapers, and personal letters of players and coaches, this history of the early crisis raises critical questions about solutions beingness negotiated at present.
On the previous page: Head to caput in an early Harvard football 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 behind the goal I was knocked insensible, simply recovered in about fifteen 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 one higher campus. In response to the tensions, a committee of football advocates had circulated a poll among former coaches and players about the game's safety and appeal. Harvey's letter was one answer. "During the summer following," information technology continued, "I was sick with blood gathering in the head and threatened with congestion of the brain, my affliction being attributed by the Doctors to the above incident."1
Harvey had returned to play the following twelvemonth, although, as he explained, "at that time I played under another name on account of family objections." He hoped that recent reforms would make injuries like his a thing of the past. "Nether nowadays rules," he posited, "it would be almost impossible for an injury to happen to a player, such as I experienced in '83."1
Harvey'south hope that the problem of caput injury in football could exist solved with technical reform is one shared by many now, more than a century later, every bit a "concussion crunch" emerges in American sports. Referring to the problem as a "silent epidemic" in a 2003 report to the Usa Congress,2 the Centers for Illness Control and Prevention (CDC) estimated in 2006 that 1.6 to 3.viii million concussions occur annually in sports and recreational activities, among which football is the greatest contributor.iii 1 study of CDC data collected in 2005–2006 estimated that 55 007 concussions occur each year in organized high-school football lonely.4 Another calculated the concussion rate during participation in football practice and competition to be 0.47 in high-schoolhouse football and 0.61 at the collegiate level. The rates approximately doubled when concussion rates were calculated for contest time only.5 Estimates vary, reflecting the challenge concussion presents to reporting and diagnosis, but it is clear in the electric current concussion crisis that head injury is not just a problem of adults. This recognition, that concussion occurs at all levels of football, from Pop 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 time.6 As sensation of the prevalence of concussion across the population swells, debates nearly its long-term health consequences have grown powerful.
The concussion crisis is commonly framed as a battle over evidence and a need for new technical solutions. Some high-profile reports accuse corporate interest groups of playing downwardly data nearly brain injury in onetime players, and others claim public wellness interest groups are playing information technology upwards.7 Corporation and player advocacy groups alike back up epidemiological investigations of the link betwixt concussion and a degenerative encephalon condition chosen chronic traumatic encephalopathy,8 and both take partnered with prestigious medical institutions to written report prevention, diagnosis, and handling.ix
Reverse to popular opinion, concussions are not a recent discovery in football, and this recent upwelling is not the first coming of the concussion crisis in American sports. Information technology emerged more a century agone, in the very first decades of football game. At that time in that location was aplenty evidence that concussion occurred frequently, and ample reason to believe that concussion could accept long-term pathogenic consequences. When this early crisis grew quiet, it was not because concussions had been eradicated, fixed, or proven harmless. Technical reforms, by some measures, had actually fabricated the concussion trouble worse. The early concussion crisis subsided because concerted work was done by football's supporters to shape and reshape public credence of hazard: to appeal to an American civilisation that permitted violence, to shift attention to reforms that addressed more visible and firsthand injuries, and to legitimize football inside morally reputable institutions. Meanwhile, changing demands on the profession of medicine regarding what kinds of bear witness constituted good medical practice left early 20th-century physicians reluctant to take a uniform and definitive stance.
This early concussion crunch in football raises critical questions virtually what kind of solutions and settlements are being negotiated in the current crisis 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 role of the larger trouble of head injury in sports today. What gained attending a century agone equally a medical problem among immature men playing football game in elite colleges is at present a serious problem of public health.
AMERICA'South MOST Dangerous PASTIME
Years before the get-go medical study of football injury was published, information technology 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 "Expressionless From Football Injuries,"11 "More than Slugging Than Playing."12 Reveling in hyperbole, i study exclaimed in 1894 that "an ordinary rebellion in the South American or Fundamental American states is as child'southward play compared with the destructiveness of a day's game."thirteen More matter of fact, another commented that "it behooves the promoters of the game to hold a briefing and prefer some measures with a view of eliminating the unsafe plays in the growing sport."14 The tone varied from newspaper to paper, city to city, only the message was clear. "The present Rugby game of football game every bit played in this state is a very risky pastime," The New York Times proclaimed, carrying "nigh the aforementioned take a chance that a soldier [assumes] on the battle field."fifteen
In these early days, higher teams standardized rules gradually. Eleven 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. There was no padding, and on the head virtually wore only a stocking cap for decoration and team identification.
Football was i among many team games that emerged in the years post-obit the Ceremonious 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 once the borderland was lost, to a compulsion to simulate wars looming on past or future horizons. Others debate that American sports emerged from a craving for community in the e'er-growing city of strangers, or a deep social anxiety about health and fitness that came with changing demographic patterns at the stop of the 19th century.sixteen The reason given at the time was stated equally though information technology were as obvious as the injuries. "The bold students," papers read, "risk life and limb to gain football honors for their colleges."17 The "triumphant football eleven" would return to their schools "covered with honors and black and blue bruises."18 What ready football apart from other squad games was that violence and bodily risk were constitutional in the appeal of the game.
In response, some colleges banned football outright. The Harvard faculty intervened twice—in 1885 and again in 1895—in light of its trigger-happy nature.xix Charles Eliot, president of the university, led the opposition. "Worse grooming for the real struggles and contests of life tin can hardly exist imagined," he wrote in his Annual Report of 1905. "Many serious injuries occur which are apparently recovered from in good measure, just which are likely to show a handicap to the victim in later life." Beyond the physical threats, he believed that "the primary objection lies against its moral quality. . . . The common justification offered for these hateful conditions 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 prey of the stronger." His opinion was unequivocal:
If a college or university is primarily a place for training men for honorable, generous, and efficient service to the community at big, in that location ought not to exist more than 1 opinion on the question whether a game, played under the actual atmospheric condition of football, and with the barbarous ideals of warfare, can be a useful element in the preparation of young men for such service.20
Others were hopeful that reform would terminate the unsightly risks. The New York Times captured this sentiment, writing "one matter is sure, and that is that our pop college sport must be modified and then as to permit of playing without danger of life and limb."21 In the Boston Globe, a footballer stated that he did "non recall the objections that have been raised to football are strong enough to atomic number 82 to its abolitionism as a college game. There are some things radically wrong most it, simply we can right them."22
Over the final 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 various competing college teams, and was heavily influenced by the leadership of Walter Campsite, known in his time as the "father of football game" for his fundamental contributions to game rules and advocacy for the sport. Military camp and the committee prepare to work saving the game through persuasive selection of evidence, technical reform, and pressure on college administrators and faculty.23
In one endeavour, mentioned at the beginning of this article, they mailed out questionnaires to players, coaches, and other aficionados, collecting "expert" opinions about the place of the game in American athletics.24 This is the questionnaire William Harvey was responding to when he detailed his "simply serious injury" that had him "knocked insensible" and "ill with blood gathering in the head." Camp compiled the many responses into a glowing 1894 volume on Football Facts and Figures that circulated widely, cited for decades equally reliable prove supporting the continuation of the game through controversy and reform.25
Harvey's response was included in Football game Facts and Figures, but merely in part. On his original letter, preserved in Campsite'south papers at Yale University, Harvey's description of his head injury has been blatantly crossed out in crayon. In the published Football Facts and Figures, Harvey's remaining testimony reads simply this:
Philadelphia, Apr 20, 1894
I consider football one of the grandest games that is played. My experience on the football field has stood me in expert stead and has taught me cocky-possession and the kinesthesia of deciding quickly and accurately. I believe that in many ways it fits a man for the business of life when he comes in contact with his beau men.
I accept been out of college for nine years but I endeavour, at every opportunity to see a skilful game of football.
Yours very truly, W. S. Harvey26
Harvey'southward message had been edited drastically, removing whatever trace of the reported head injury.
Equally evidence similar this was selectively silenced and circulate in the interest of the game, a series of dominion reforms was existence tested on the field. The legalization of the forward pass was one. New possession rules and the creation of the quarterback position were others.27 These rule changes opened upwardly the game, making fouls more visible to referees and reducing momentum plays. They also made the game more interesting for spectators to scout.
The watchdogs of player safety were non impressed with the outcomes of the rule reforms. "The new rules," wrote one, "which were expected to accomplish so much in reducing the record of injury to players, failed entirely of their purpose."28 The response to the failings of the outset reforms was more than reforms, while the game grew ever more entertaining.29
American football helmets have evolved over time while the problem of concussion persists. Printed with permission, Smithsonian Institution Collections, National Museum of American History, Behring Center.
THE CONCUSSION CRISIS BEGINS
As anxiety mounted over the death of a student from head injury in 1906,30 the Harvard Higher team doctors released a damning and unambiguous report on "The Physical Aspect 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 confronting the game from its medical standpoint." Their article, systematically documenting the nature and number of injuries sustained past the team over the 1905 flavor, highlighted 1 injury in particular that had been hiding in plain sight: concussion of the brain.
The concept of brain concussion had been traveling through mutual and medical usage for centuries. As early on as the mid-16th century it had been divers as a accident resulting in escape of blood from ruptured tissue. Past the early on 19th century it was described equally 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 care for concussion as a joke, it was clear that "when a status like this develops as the outcome of an injury, the key nervous system has received a very astringent shaking upward." The doctors could non extrapolate from their small, one-flavour sample to make strong claims about the long-term consequences of concussion, and neurologists had non studied football injuries in item, simply those tasked with judging evidence for policy and practise took a stance. The American Medical Association reported that, although
there was a time when information technology was considered that convulsions and other untoward incidents of the unconscious life of the individual were not likely to exist followed by serious consequences, this is not the opinion at the nowadays time.33
Head injury from other causes had provided prove of concussion's risks: railroad train collisions, frequent in the belatedly 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 i flavor alone in that location had been no less than nineteen concussions, and although some football advocates had guessed that simply big games between 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 particularly to close contest in big games."35 The public received word of the doctor's "amazing statements with reference to the frequency and nature of the injuries sustained" from the popular press, which noted that "the nearly surprising fact he states is with respect to brain concussions."36 The American Medical Association picked upward on this extraordinary statistic, too, commenting that
perhaps the well-nigh serious feature of these accidents is the number of concussions of the encephalon reported. Simply two games were played during the unabridged 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, equally the crusade of death or hospitalization. The stupor with the statistics of the 1906 paper was not that concussions were happening, but that they were happening in nigh every game without such obvious evidence. According to the BMSJ report, a concussion could occur without even the player himself realizing it. "The injury was ofttimes noticed by a surgeon from the side lines earlier information technology was recognized past the players," the authors explained. "A actor might automatically run through a considerable serial of plays earlier his fellows noticed that he was mentally irresponsible."38 Concussion was deemed something that could happen almost invisibly in the noise and activity of a game. The concussion crunch had begun.
VISIBLE ENOUGH TO COUNT
The turn of the century was a time of heightened awareness to injury. The industrializing workplace was a infinite where accidents inspired worker's compensation constabulary, devastating mill fires alerted the public to a need for rubber regulations, and the complication of issues led to the formation of national councils to oversee them.
In this context, some physicians expressed frustration that their peers paid too little attending to head injuries. "We all know that any impairment of the brain seriously affects the unabridged economy," wrote ane. "Why not give them that consideration their importance entitles them to?"39 He blamed "carelessness" in the treatment of fifty-fifty the most obvious skull fracture for the "subsequent suffering" seen in victims of head injury. Treating observable injuries like fractures with balance, symptom direction, and reduction of stimulation might, he postulated, also care for invisible injuries in inaccessible parts of the brain:
Every case of recent caput injury, all the same niggling it may appear, should, we believe, be treated with the greatest consideration, lest damage to subconscious and important structures escape our attending, thus leaving a foundation for time to come trouble which also ofttimes is irreparable. . . . Unless our range of enquiry is sufficiently comprehensive to accept in all possibilities, deeper injuries may remain, to be followed by headache, epilepsy, or fifty-fifty insanity.xl
Merely lack of medical attending was not merely the event of carelessness. Around the aforementioned time that football game was becoming 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 need was emerging for experimentally supported, bear witness-based diagnoses and therapies. Physicians were increasingly expected to rely on technical diagnostics—visualization technologies that would requite proof of the presence of a pathology—and experimental, statistical proof to dorsum their prescriptions.41 These kinds of scientific evidence were exceedingly difficult to excerpt from the occult regions of the encephalon and the hidden processes linking encephalon and beliefs over time.
Physicians were all besides aware of their inability to produce visual evidence. Injury, they conceded, could occur in the brain without visible damage to the caput. But there were serious constraints to proving this in a living person. For injury subconscious below skin and os and inches of seemingly unaffected encephalon tissue, there was no easy ways of detection, no "rational surgical procedure based on scientific discipline and common sense" as there was for fractures of the skull and visible violent 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, non trauma to soft tissue.44
Physicians recognized that limitations in imaging the brain were limiting their power to scientifically understand not only the injury itself, but as well long-term psychological effects. In that location was no agreed mechanism, no theoretical consensus, for how concussion injured the brain. Older doctors forwarded a mechanical theory that
cerebral concussion, by causing inflammation of the meninges which spread to the brain, disorder its circulation and diet and thus produce psychic disease, at once or later a long interval.45
Others hypothesized that concussion changed the brain'south molecular composition. "With or without fabric injury," i wrote,
the shock produced past the blow may crusade molecular change in the encephalon, thereby producing psychic disturbances or a predisposition, particularly in neurotic individuals . . . insanity may not occur until after a long interval, during which no special symptoms occur.46
Merely in the absence of imaging, the latent flow between traumatic injury and behavioral symptoms proved a barrier to building an evidence-based theory. The mechanical theory was non
sustained by the facts found in many cases, for the reason that the surgeon and pathologist have failed to show a land of facts. If such lesions did exist they would take given recognizable symptoms (which actually have been entirely absent) during the interval.47
And the molecular theory foundered on the conclusion that there was "no proof of any such molecular changes if they produced no recognizable atmospheric condition."48
As these theories faltered for lack of show, a different theory based on pathological findings was gaining support. Researchers had identified tiny capillary hemorrhages surrounded past softened brain tissue in heads known to take been concussed,
generally located in the surface of the brain below the contused office, simply oft as well deep down around the ventricles or in the portion of the encephalon diametrically reverse the injured portion.49
Others had linked these hemorrhages to behavioral change. "Not infrequently later injuries to the head," i wrote, "a very decided change is seen in the mental condition. . . . In at least some of the cases there are minute hemorrhages of minute areas of softening throughout the brain acquired past trauma."50
Causal links betwixt concussion, hemorrhaging, and behavioral changes were difficult to substantiate. Although many suspected that concussion caused both insanity and alcoholism, this was hard to evidence when not everyone hit in the head became drunk or insane. Some thought caput injury merely acted as a mediator, exacerbating preexisting atmospheric condition and speeding up their course. Others idea the head injury could but act as a cause in people who were predisposed by hereditarily weak constitution. To control for competing ideas the researchers required that, to exist counted as a example, a corpse must accept been in good health earlier the concussion result and that "the symptoms must be of singled-out development and must come on within a reasonable time."49 This express what kinds of effects could exist seen, counting out side effects or symptoms that did non present until after in life. And it made it even more difficult to power a study specifically investigating concussion associated with football.
SHIFTING RISK TO THE BRAIN
New padding, new rules nigh mass tackles, and other game reforms began to reduce injuries to "life and limb," statistically improving morbidity and mortality reports on the kinds of injuries that could be measured.51 Only, in doing so, reform shifted risk to the more scientifically ambiguous areas of the brain and life outside the football spotlight. "Football Dead 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 Still Big. Cases of Concussion of the Brain Increment." The article highlights a growing incidence of concussion:
Concussion of the brain was the leading cause for the deaths this year, as has been the case in the past, but information technology led by a much higher proportion than in either of the 2 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 not fatal also showed a large increase.52
This shift of risk to the brain continued fifty-fifty as medical authorities wrote more and more confidently about the links between nonfatal concussion and mental disorder. By 1911 a Periodical of the American Medical Association (JAMA) article, summarizing the work of a number of German language psychiatrists world-renowned for their neurologic research, claimed that a constellation of mental disorders shared a "common etiologic factor, namely, trauma to the head."53 Acknowledging that not every person who was hit in the head adult the same outcomes, it was distinguished that
injuries which produce an extensive, diffuse shaking up or shattering of the encephalon tissue, such as occurs in concussions or those which produce extensive pressures on the brain, will be followed by mental disturbances.54
Their visual description of concussion reinforced the growing consensus effectually a mechanism of lengthened microscopic changes in the brain, characterized by minute hemorrhages and softenings, and their research linked this physical change to behavioral change. Concussion could "be followed past no untoward, firsthand symptoms," the article noted, continuing:
The patient may not even lose consciousness, just walk to his dwelling and apparently not be the worse for the feel, until afterwards—sometimes weeks and even months after—he begins to prove a very noticeable change in his psychic total. His entire mental make-up changes, he becomes easily tired, is incapable of any prolonged mental attempt, is forgetful, irritable and distractable. He complains of vertigo, pressure level 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 vehement temper on the least provocation.55
Although the classification of this psychosis was not entirely clear, the authors were sure that "those who knew the private before the injury will invariably discover" the alter.56
The JAMA report concluded with a articulate exhortation that the medical customs treat concussions not merely as astute injuries, but according to the "effects the injury volition take on the patient's future life." These injuries had the potential to rob the "faculties which bring about an adjustment between individual and environs," and if the injury was non fatal, "the question of paramount importance which then comes up is . . . one of a more far-reaching importance, namely, 'How will the future life of the patient be modified past this injury?'"57 The fact that in that location were instances in which at that place was liability law–induced malingering did not detract from the existent cases, and physicians were urged to take seriously "the importance of this class of mental disturbance for the general practitioner, and specially for the practicing neurologist." It could
hardly be overestimated, especially when we remember that according to Friedman's statistics, 60 per cent of all concussions to the brain are followed by psychic disturbances for a year or more than later on the injury, and that co-ordinate to Ziehen, the traumatic psychoses form three per cent of all admission to hospitals for the insane.57
On the basis of the neurologic literature and the serial of cases, the report ended that
caput injuries may have a lasting deleterious effect on the individual that while a cantankerous section at any particular point may not evidence any gross pathologic findings, nevertheless a study of the entire individual's 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 drunk" boxers after death, showing that such injuries and effects could occur in sport.59 Just no studies were washed on football until much later in the century.
INCENTIVES TO DOUBT
Football survived its start concussion crisis not because of lack of evidence or because the problem was technically solved, but because its promoters worked to make football's perceived contribution to social values greater than its risks. Certainly, there were financial stakes in football game. The sport emerged in an era of unfettered betting among both players and spectators. One newspaper noted that, before a game in 1893, students stayed up all night and "those youngsters bet as though the war was going on."60 Bankers on the floor of the Stock Exchange in New York bet larger amounts amidst themselves, where one had "bet $500 that Princeton would not score, and said that he had $1500 more to wager on the aforementioned 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 Football Association in 1920 only deepened the incentive to continue the game and ignore its inherent risks. Dissimilar the higher teams, made up of elite youths playing an unpaid game, the professional league was a collection of men paid a bacon. A by lack of attending 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 loftier schools. As Harvard Able-bodied Director William Bingham wrote in 1935,
there has been pressure level from the professionals, and I recollect I sense a trend on the part of some colleges to eyebrow some of the things they decided to discard a half dozen years agone.62
But financial interests were non lonely in sustaining the game. Football game likewise tapped a cultural penchant for strength and stimulation in a society tolerant of violence. In football's early and uncertain days, boosters worked actively to align the rhetoric virtually football with the civilisation of the fourth dimension, to enmesh the game in the moral interests of the elite colleges, and to suppress evidence of the game's risks while promulgating prove of the game's comeback. Information technology appealed to anxieties nearly America's relative lack of fitness, and appealed to a civilization of manliness pervasive in the early 20th century. Choosing to take on risk, demonstrating skill and loyalty—all of these were characteristics of the manly ideal.63 Reforms claimed to brand the game more than "scientific," appealing to a culture that believed that a game, if played "scientifically," could exist played without danger.64 This illusion of a scientific and injury-free game survived even after reforms repeatedly failed to remove the take chances. Public claims were made that "skillful players are less liable to injuries. . . . Playing to the bespeak of burnout should exist avoided. Proper padding as well prevents injuries."65
All the while, the ascent incidence of concussion was plain forgotten. Inside the colleges of the fourth dimension, there was a sense that their role was to not just brainwash in academics simply also to turn boys into men. Although a few university leaders argued that toughness could come from less-violent able-bodied activities, they were out-voiced by coaches and fifty-fifty powerful politicians lobbying for the special values of football game.66 As Harvard'due south Bingham wrote, "no young man can play football nether [Jitney] Harlow without existence a amend man when he is through. By this I do non mean physically but in every style that makes for manhood."67 The manly quality of loyalty further masked the bear witness of the dangers inherent in the sport. It meant not doing things that could damage the reputation of the team, but it also meant upholding the game. "We must have loyalty!" Bus Harlow wrote to the able-bodied manager. "Football takes enough price of ones brains and energy in the fall without the insidious cancer of disloyalty eating out the vitals of the organization."68 This meant not standing to feed news of injury to the public sphere through the newspapers and medical journals, with pressure coming non only within the academy merely likewise nationally. "As I told you lot," a fellow member of Wisconsin'south Interscholastic Athletic Clan wrote to Harvard's Dean Delmar Leighton in 1935,
I desire no member of the football staff writing for the papers. I feel our job should consume all of our fourth dimension 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
Fifty-fifty members of the Rules Committee steered articulate of the public in protection of the game. One of import and well-respected committee member, William Langford, became then upset at the internal handling of player safe that he resigned. "In that location is non the slightest doubt in my mind that encouragement of the 'slow whistle' is a direct invitation to roughness and injury,"70 he wrote in conviction to the Harvard athletic director. Merely instead of speaking out most the incongruity, he left quietly. "I have purposely kept the matter quiet because publicity of any sort would exist harmful to the game," he confided in closing.71
1 of the cracking conundrums of the manly ideal in football is that it came to crave the participation of immature boys. In its early days, children had been excluded. "Football is non a sport for boys by any means, and young men ought to be potent in the first identify and be assured of skilful coaching in the 2d before they tackle information technology," i paper reported the common conventionalities.72 But inside the next few decades, secondary school 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, Primary Chamberlain of Milwaukee's Riverside High School wrote to Dean Delmar Leighton of Harvard College urging that the rules not be changed to brand 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 ane fifth of that in the colleges. By this accounting, he ended that made "high schoolhouse football game a proficient deal safer than that in college when we consider the number of players engaged."73 The paradigm of the high-schoolhouse game was "as much to the interest of colleges as it is to the loftier schools," he warned. "Should football game in secondary schools receive a black heart, and so the game in the colleges will certainly be afflicted."
Above and Correct: Images on the website of Riddell, the company that makes the "Official Helmet of the NFL," appeal to parents with the message that they can be good parents by ensuring their children habiliment helmets. Others on the site reinforce the cultural thought that putting immature children in warrior-like scenes is natural and desirable.
FOR THE LOVE OF THE GAME
Reform of the game rules sustained a contemplative hope that the game could exist made passably safe through technical fixes, which came to include protective equipment for the body also as rule reform. Only hope, and the limitations of research methods to detect unintended consequences, covered up an uneasy sense that the technical fixes were not solving the problems. "I think nosotros should consider at our coming together this wintertime the whole question of the present equipment," said Walter Okeson, Commissioner of the Eastern Intercollegiate Association, in 1935. "I sometimes wonder if some of the equipment is not causing as many injuries as events."74 The comment was raised by a question Bingham had posed to members of the rules committee that year. "In connection with equipment," he said, "I am wondering if the Rules Commission will brand any recommendation next year 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, first required among college footballers in 1939. The plastic football helmet was amended to include a face mask in 1956. Through the 1960s plastics were improved and then that the helmets no longer shattered as easily equally the initial incarnations. Early business concern focused on preventing skull fracture more than than concussion,76 but growing interest in injury prevention eventually brought greater attention to injury to the head and spine more mostly. In the early 1970s air bladders were added to "energy-absorbing helmets" and 4-point chin straps were required at the collegiate level after 1976.
Over the adjacent 2 decades scientific and media attention effectually concussions in professional football game grew. By the mid-1990s concussions were making the news again. The New York Times reported simply earlier the 1994 Super Bowl that star quarterback Troy "Aikman's concussion has focused attention on a dangerous and recurring injury in the National Football game League."77 Through these decades, new regulations, new brain imaging technologies, and attention to youth sports injury were meaning in the re-emergence of the crisis.78 By 2002, Riddell Sports produced a new official helmet design for the National Football League (NFL) that was primarily "intended to reduce concussion," according to the league's Web site.79
Although high-finish helmet pattern over the past century has led improvements in protection, helmets have regrettably not solved the public health problem. It is an indication of the intractability of this problem that, by 2011, the new helmet offerings were not solutions, but rather "impact indicator" mentum straps, collecting data on the concussive blows that persisted despite walls of air, plastic, and skilled design.
Neither have solutions been found in clinical treatment of concussion, which has non avant-garde 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 accept influenced official recommendations about return-to-play decisions.80 Near states have passed legislation requiring education, removal of a concussed athlete from the game, and medico clearance earlier returning to play.81
And all the same, 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 firsthand 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 manufacture began labeling cigarette packages with Surgeon Full general's warnings about the risks inherent in tobacco smoking, some saw this as a success for public wellness as well. With time, all the same, the legal loophole that this label created for the tobacco corporations became apparent. In one case the users had been warned that the production was dangerous, the gamble became their ain and not the responsibility of the visitor or the public who permitted the product to exist sold.83 The NFL's labeling of locker rooms with posters likewise individualizes responsibility, institutionalizing the idea that it is the actor'due south responsibility to recognize and presume the hazard of concussion. Electric current National Collegiate Athletic Association guidelines, besides, expect student athletes to self-report signs and symptoms of concussion to their medical staff.84
This expectation is contraindicated not only by the visual quietness of serious head injury in the loud frenzy of a game, but also by an honest evaluation of the stakes and power differentials in the decision, which asks people to decide whether to brand this career- and team-changing determination in the confront of a multibillion dollar networked corporation and a culture of loyalty and strength that is notoriously tolerant of violence. And it neglects the reality that adult football players start as children, and that the structure of the professional corporation depends on these children coming upwards through the ranks—not but the few children who will e'er play professionally merely also all the children who never will. All are subjected to known risks, with the blessing of their watching friends, parents, and teachers.
END ZONE
Better ways of reducing the risks of head injury may exist found through loftier-profile collaborations of medical science and football game corporations. But the long history of the concussion crisis tells us that, although the pursuit of fixes is well and practiced, proponents of fixes demand to know their enemies: the financial interests that support the condition quo, and the cultural assumptions linking football game, violence, and our electric current iterations of manliness.85 Steps must be taken to ensure that prophylactic and honest interpretations of science drive the research that is washed and the conclusions that are reached.
The ultimate challenge to building and implementing good policy may be that football game became popular non despite its violent aspects, but considering of them. The near constructive interventions will surely be integrative of improved technical protections, regulatory modifications, enforcement of rules and policies, and public pedagogy, also as diagnostics and treatment of the injuries that volition continue to occur. But the mass popularity of dangerous sports inhibits the interventions that might exist virtually effective at all levels—from youth to collegiate to professional person. The inherent dangers of the game will keep nether the cloak of monetary settlements like that announced in August 2013.86
This was acknowledged among even the very earliest discussions near American football game's concussion crisis. "An endeavour has been made to gloss over football'south worst aspects by widely published suggestions that no game is entirely without the danger of death nether accidental circumstances," JAMA reported in 1906. Just the injuries are "absolutely dependent on the present methods of playing the game itself, and spring to occur." The fact that so many injuries
occur in ane season of play is of itself enough to stamp on the game as something that must be greatly modified or abandoned if we are to be considered a civilized people, and if our universities are to be considered centers for influence for proficient.
The realities of the game should be its death knell, the writers argued, unless authorities "fear unpopularity more than they dare to exist correct."87
Acknowledgments
Thank you to Allan Brandt and David Jones for conscientious reading and advice. I am grateful also to Charles Rosenberg for discussions on an early draft and to the reviewers for their helpful comments.
Human Participant Protection
Institutional review board approval was not required as this study did not involve homo participants.
Endnotes
1. Walter Chauncey Camp Papers (MS 125). Manuscripts and Archives, Yale University Library.
2. National Center for Injury Prevention and Control, Study to Congress on Balmy Traumatic Brain Injury in the United states: Steps to Foreclose a Serious Public Wellness Trouble (Atlanta, GA: Centers for Disease Control and Prevention, 2003).
3. J. A. Langlois, W. Rutland-Brownish, and Grand. Chiliad. Wald, "The Epidemiology and Impact of TBI: A Brief Overview," The Journal of Head Trauma Rehabilitation 21, no. 5 (2006): 375–378. [PubMed]
4. Centers for Disease Control and Prevention, "Sports-Related Injuries Among High Schoolhouse Athletes—United States 2005–06 Schoolhouse Yr," Morbidity and Mortality Weekly Report 55, no. 38 (2006): 1037–1040; P. R. Shankar et al., "Epidemiology of Loftier School and Collegiate Football Injuries in the U.s.a. 2005–2006," The American Journal of Sports Medicine, no. 8 (2007): 1295–1303.
5. L. M. Gessel et al., "Concussions Amid US High School and Collegiate Athletes," Periodical of Athletic Training 42, no. 4 (2007): 495–503. Rates are calculated per k athlete-exposures, i.due east., for every thousand participations in a practice or a competition.
vi. 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 xvi, no. 6 (2009):755–763; Centers for Disease Control and Prevention, "Nonfatal Traumatic Encephalon Injuries Related to Sports and Recreation Activities Amongst Persons Anile ≤19 Years—United States, 2001–2009," Morbidity and Mortality Weekly Written report 60, no. 39 (2011): 1337–1342.
7. For example: 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. Run across also the Sports Legacy Institute Web site at: http://www.sportslegacy.org. [PMC free article] [PubMed]
ix. The National Football League Players Association has granted Harvard Medical School $100 one thousand thousand for a x-twelvemonth initiative to practise but this: D. Cameron, "HMS Partners With NFL Players Clan," Harvard Gazette, Jan 29, 2013, http://news.harvard.edu/gazette/story/2013/01/nflpa_hms_initiativ (accessed Feb v, 2014)
x. "A Student Killed at Football," New York Times, October 22, 1887.
11. "Dead From Football Injuries," New York Times, November thirteen, 1903, News sec.
12. "SISS-Blast-AH, More Slugging Than Playing," Boston Daily Globe, November 13, 1887: iv.
13. "Yale Again Triumphant," New York Times, November 25, 1894, News sec.
14. "Modify the Football Rules: The Rugby Game equally Played Now Is a Dangerous Pastime," New York Times, December two, 1893, News sec.
15. Ibid.
xvi. 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 University Printing, 2001)
17. "Set up for the Great Struggle," New York Times, Nov xxx, 1893.
18. "Harvard Forfeits: Championship Game to Yale Kickers," Boston Daily Earth, November 26, 1888: 5.
19. Harvard University, Almanac Reports of the President and Treasurer of Harvard College, 1894–1895, http://pds.lib.harvard.edu/pds/view/2574409?northward=3226 (accessed July 25, 2013): "The evils of football at present became and so great that the Faculty, in January 1885, prohibited all intercollegiate football games. This prohibition was maintained for ane year. In the spring of 1895, the Kinesthesia adopted a vote (Feb 19) 'that the Faculty desire the Committee to put a stop to all intercollegiate foot-ball contests.' . . . On the 19th of March, the Kinesthesia adopted the following vote: 'The Faculty, having received and considered a communication from the Committee on the Regulation of Athletic Sports, dated Feb 25, 1895, remain of the opinion that no pupil under their accuse should be permitted to accept part in intercollegiate foot-ball contests'; but on the 7th of May, a resolution 'that the Faculty of Arts and Sciences will not allow a pupil nether their charge to take office in any intercollegiate pes-ball contest' was lost by a decisive vote.".
20. From President Eliot's Annual Report for 1903–4: 18–22. Records of the President of Harvard University Charles William Eliot. Pusey Athenaeum, Harvard University. Box 220/164.
21. "Change the Football Rules," New York Times.
22. Editorial, Boston Globe, February 3, 1905. The same editorial reported some other footballer maxim that Eliot "certainly hit things pretty most right. I didn't realize the president knew so much nearly the game. There is no getting around his argument on the morality of the game, but information technology would non take much to correct them. If we had some officials who had the courage to enforce the rules, and enforce them to the limit, the trouble would be solved.".
23. See, for example, messages collected in Records of the President of Harvard University Charles William Eliot, Pusey Archives, Harvard Academy, Box 87 (folder Football, 1906)
24. Walter Chauncey Camp Papers (MS 125), Manuscripts and Archives, Yale University Library.
25. A. Ronald, Smith, Sports and Liberty: The Rise of Big Time Higher Athletics (New York, NY: Oxford University Press, 1988)
26. Walter Camp, editor, Football game Facts and Figures: A Symposium of Expert Stance on the Game'south Place in American Athletics (New York, NY: Harper and Brothers Publishers, 1894): 167–168.
27. "Changes in Football," The Harvard Ruddy 48, no. 82 (1906); meet also John J. Miller, The Big Scrum: How Teddy Roosevelt Saved College Football (New York, NY: Harper Collins, 2011). Northward.B. The facts are useful, merely the tone of this book is an exhibit of the macho attitude critiqued in this article, and non my analysis of the history.
28. "Yale Again Triumphant," New York Times.
29. In a letter during the autumn of 1905, Harvard's President Eliot noted the significance of the shift. "My own stance is that intercollegiate football ought to be forbidden to Harvard students," he wrote. "Simply I exercise not know that the Governing Boards of the University are now ready for that step. In that location has undoubtedly been a great change of public opinion nigh the value of football inside the concluding two years." (Letter from Eliot to Mr. A. Yard. Foerster, November 23, 1905, Records of the President of Harvard Academy Charles William Eliot, Pusey Archives, Harvard University, Box 194 [folder, Intercollegiate Football 1905])
30. Miller, The Big Scrum.
31. E. H. Nichols and H.B. Smith, "The Physical Attribute of American Football game," Boston Medical and Surgical Journal (1906):1.
33. "Surgical Aspects of Football," Periodical of the American Medical Association 46, no. 2 (1906): 123.
34. "The Railway Spine," Railway Times eighteen (November 24, 1866)
35. "Surgical Aspects of Football": 123.
36. Harvard Plans Reform of Football Rules," New York Times, January 6, 1906; "Injuries in Football game at Harvard," Boston Daily Globe, January 5, 1906.
37. "Surgical Aspects of Football": 123.
38. Nichols and Smith, "The Physical Aspect of American Football": 3.
39. West. H. Earles, "Necessity for More Intendance in the Treatment of Skull Fractures," Journal of the American Medical Clan 41, no. 3 (1903): 170.
forty. Ibid., 169.
41. For more on this shift see Harry Marks, The Progress of Experiment: Scientific discipline 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. Eastward. Rosenberg and M. J. Vogel, eds., The Therapeutic Revolution: Essays in the Social History of American Medicine (Philadelphia, PA: University of Pennsylvania Press, 1979); J. H. Warner, "Ethics of Science and Their Discontents in Late Nineteenth-Century American Medicine," Isis 82 (September 1991); A. Cunningham and P. Williams, editors, The Laboratory Revolution in Medicine (Cambridge, MA: Cambridge University Printing, 1992). Encounter as well J. D. Howell, Technology in the Hospital: Transforming Patient Care in the Early on Twentieth Century (Baltimore, Medico: Johns Hopkins University Press, 1995) and D. S. Jones, Cleaved Hearts: The Tangled History of Cardiac Care (Baltimore, Dr.: Johns Hopkins University Printing, 2012) for discussion of visualization technologies in medicine.
42. Earles, "Necessity for More Care in the Treatment of Skull Fractures":169.
43. "Tumors of the Encephalon," Journal of the American Medical Association 20, no. half dozen (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," Journal of the American Medical Association 53, no. 14 (1909): 1081–1084.
46. Ibid., 1081.
47. Ibid.
48. Ibid.
49. "The Remote Effects of Head Injuries," Journal of the American Medical Association 42, no. six (1904): 380.
50. C. W. Burr, "Trauma of the Caput as a Crusade of Insanity," Journal of the American Medical Association 48, no. 1 (1907): 33–37.
51. E. H. Nichols and F. L. Richardson, "Football Injuries of the Harvard Squad for Three Years Under the Revised Rules," Boston Medical and Surgical Journal (1909): lx. [PubMed]
52. "Football Dead 14 With the New Rules," New York Times, Nov 20, 1910.
53. B. Glueck, "Traumatic Psychoses and Post-Traumatic Psychopathic States," Journal of the American Medical Association 56, no. 13 (1911): 943–948.
54. Ibid., 945.
55. Ibid., 944.
56. Ibid., 945.
57. Ibid., 947.
58. Ibid., 948.
59. Harrison Southward. Martland, "Punch Drunk," Journal of the American Medical Association 91, no. xv (1928): 1103.
sixty. "Gear up for the Peachy Struggle," New York Times, Nov xxx, 1893.
61. Ibid.
62. William Bingham, Letter to Wm Langford, 11 November 1935, Harvard Athletic Association Archive, box 8, folder "Football Rules Committee 1935-8," Harvard Academy Archives.
63. Run across, for example, H. C. Mansfield, Manliness (New Haven: Yale Academy Press, 2006); G. Bederman, Manliness and Civilization: A Cultural History of Gender and Race in the United States, 1880–1917 (Chicago, IL: University of Chicago Press, 1995); James R. McGovern, "David Graham Phillips and the Virility Impulse of the Progressives," The New England Quarterly 39 (1966): 335.
64. "A Football Player'south Fatal Hurt," New York Times, October 22, 1892.
65. "Football at Harvard," New York Times, March 7, 1909.
66. Harvard'due south President Eliot, for instance, thought rowing would inculcate the kinds of toughness best suited to a life of business and other professions. Annual Report 1903–4:18–22. Records of the President of Harvard Academy Charles William Eliot. Box 220/164. The last line is moving: "Civilization has been long in possession of much higher ideals than those of war, and experience has abundantly proved that the highest efficiency for service and the finest sort of backbone in individual men may be accompanied past, and indeed spring from, unvarying generosity, gentleness, and good volition.".
67. 50. D. Worsham, Director of Athletics, Army Able-bodied Association, West Signal. Alphabetic character to William J. Bingham, Managing director of Athletics, Harvard, 7 Jan 1935, Harvard Athletic Association Archive, box 7, binder "Richard Harlow 1935," Harvard University Archives.
68. Richard C. Harlow, Alphabetic character to William Bingham, 21 January 1935, Harvard Athletic Clan Archive, box 7, folder "Richard Harlow 1935," Harvard University Athenaeum.
69. G. A. Chamberlain, Board of Control Wisconsin Interscholastic Athletic Association, Milwaukee, Letter to Dean Delmar Leighton, 9 University Hall Cambridge. 3 Dec 1935. Harvard Athletic Association Annal, box 8, folder "Football Rules Committee 1935–8," Harvard Academy Archives. Chamberlain wrote to the Rules Committee to forestall reform of the high-schoolhouse game rules, saying that "for the adept of the game I am of the opinion that reports which are sent out from some quarters in the Eastward should be strenuously discouraged.".
70. A "slow whistle" refers to a referee'due south wait to accident 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 diddled until he was completely immobilized; otherwise he could get up and run once more.
71. William Langford, New York, Letter to Wm Bingham, 12 November 1935, Harvard Athletic Association Annal, box eight, binder "Football Rules Commission 1935–8," Harvard University Archives.
72. A Football Role player's Fatal Hurt," New York Times, Oct 22, 1892.
73. Ibid.
74. Walter Okeson, Commissioner Eastern Intercollegiate Association, Letter to Wm Bingham, 24 October 1935, Harvard Athletic Association Archive, box 8, folder " Football Rules Committee 1935–8," Harvard University Archives.
75. William Bingham, Letter to Walter Okeson, 22 Oct 1935, Harvard Athletic Association Archive, box viii, binder "Football game Rules Commission 1935–8," Harvard University Archives.
76. Come across, e.m., John Sayle Watterson, College Football: History, Spectacle, Controversy (Baltimore: Johns Hopkins Academy Printing, 2002); John South. Watterson, "Inventing Modern Football" American Heritage Mag 39 (1988): 102.
78. Run across, for example, S. G. Gerberich et al., "Concussion Incidences and Severity in Secondary School Varsity Football game Players," American Journal of Public Wellness 73, no. 12 (December 1983): 1370; F. O. Mueller and R. C. Cantu, Nineteenth Annual Study of the National Eye for Catastrophic Sports Injury Research: Autumn 1982–Bound 2001 (Chapel Hill, NC: National Center for Catastrophic Sports Injury Enquiry, 2002)
eighty. Chiliad. M. Guskiewicz et al., "Cumulative Effects Associated With Recurrent Concussion in Collegiate Football Players: The NCAA Concussion Study," Journal of the American Medical Clan 290, no. 19 (2003): 2549–2555; McCrory et al., "Consensus Statement on Concussion in Sport.". [PubMed]
81. Centers for Illness Control and Prevention, "Injury Prevention and Control: Traumatic Brain Injury," http://www.cdc.gov/concussion/policies.html (accessed September one, 2013)
82. Encounter, for example, "Poster 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. fourteen (2010): 1293–1296.
83. Allan M. Brandt, The Cigarette Century: The Rise, Fall, and Deadly Persistence of the Product That Defined America (New York, NY: Bones Books, 2009)
84. 2012–13 NCAA Sports Medicine Handbook, vol. 56 (Indianapolis: National Collegiate Athletic 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/judge-announces-settlement-in-nfl-concussion-suit.html?_r=0 (accessed September one, 2013); Gary Mihoces, "NFL Reaches Concussion Settlement," Us Today, August 29, 2013, http://world wide web.usatoday.com/story/sports/nfl/2013/08/29/nfl-concussion-settlement-judge-anita-brody-tony-dorsett-jim-mcmahon-junior-seau/2727483 (accessed September 1, 2013)
87. "Surgical Aspects of Football game": 123.
Articles from American Journal of Public Wellness are provided hither courtesy of American Public Health Association
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3987576/
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