Awareness of football’s concussion dangers goes back 100 years

Yesterday’s Super Bowl marked the end of a highly contentious year for the NFL — one marked by scandals involving domestic violence, controversial officiating, possible cheating (Deflategate) and the overprescribing (perhaps illegally) of prescription painkillers.

But running underneath that cacophony of controversy, like a low and steady bass line, was the ongoing issue of concussions and related traumatic brain injuries. The NFL hopes, of course, that its settlement offer of $765 million for the neurological testing and care of retired players diagnosed with such injuries will put the matter to rest.

But will it? Will the issue just go away? Or will it, as some have suggested, eventually, bring about the end of football?

Well, if past is prologue, then the NFL has nothing to worry about. For, as Emily Harrison, a doctoral candidate in the history of science at Harvard University, explains on the science-medicine-anthropology website Somatosphere, “people knew over a century ago that head injuries in American college sports were dangerous. This present distraction and these proffered settlements are not the first time that the serious issue of head injury has been brushed under the rug.”

“Society forgot what it knew because significant work was done by football’s supporters to hush up evidence in the media and other popular discussions, to discourage scientific research, and to legitimize football by allying it with morally-reputable institutions and with cultural ideals of manliness that carried great weight at that time,” she adds. “What was known was unlearned, forgotten, pushed away into a corner. Over time, the first surge of the concussion crisis settled away into the storage bins of history.”

The first concussion crisis

Harrison documents that history in a fascinating article she wrote last year for the American Journal of Public Health. From football’s earliest days in the mid-1880s — and long before any medical study of football injury was published — the dangers of the game were well recognized. In 1905, a year in which 18 young men died while playing football in the United States, the president of Harvard University (which had banned the sport for several years in the 1890s after a particularly brutal Harvard-Yale game sent several players to the hospital) wrote that a “worse preparation for the real struggles and contests of life can hardly be imagined.”

He also acknowledged that it wasn’t only fatal injuries that were the problem. “Many serious injuries occur which are apparently recovered from in good measure, but which are likely to prove a handicap to the victim in later life,” he said.

A year later, a group of Harvard physicians published a widely reported paper in a medical journal in which they identified concussion as one of the major dangers of the sport. They also emphasized that concussions happened frequently and not only in “big” and highly competitive games, as was commonly believed at the time.

Many other medical warnings about football-related head injuries followed. In 1911, an article in the Journal of the American Medical Association (JAMA) described the symptoms of concussion in words that will sound familiar to anybody who has followed 21^st-century medical literature on this topic:

The patient may not even lose consciousness, but walk to his home and apparently not be the worse for the experience, until later — sometimes weeks and even months later — he begins to show a very noticeable change 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 distractible. He complains of vertigo, pressure sensations in his head, 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 least provocation.

Another JAMA article published around the same time had this to say: “An attempt has been made to gloss over football’s worst aspects by widely published suggestions that no game is entirely without the danger of death under accidental circumstances. [But the injuries are] absolutely dependent on the present methods of playing the game itself, and bound to occur.” 

News rules and equipment

In response to these damning reports, football officials revised and standardized the rules of the game. Padding and other equipment were also eventually added — most notably plastic rather than leather helmets. These changes had the effect, says Harrison, of reducing certain types of injuries — such as skull fractures — but not concussions.

“Reforms claimed to make the game more ‘scientific,” appealing to a culture that believed that a game, if played ‘scientifically,’ could be played without danger,” writes Harrison. “This illusion of a scientific and injury-free game survived even after reforms repeatedly failed to remove the risk.”

Unfortunately, however, the early 20th-century doctors who recognized that football reforms were producing only an illusion of safety had little evidence with which to make their argument. The absence of brain-imaging technology made it impossible for them to directly link concussions with later behavioral symptoms.

Culture and money

But, as Harrison points out, “football survived its first 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.”

“In football’s early and uncertain days,” she writes, “boosters worked actively to align the rhetoric about football 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’s risks while promulgating evidence of the game’s improvement.”

College players were pressured by their coaches and teammates to be “loyal” to their teams and their school and not report any injuries, she adds. That message also worked its way down to the high school level. Indeed, in 1935 a Milwaukee high school principal wrote to a dean at Harvard, asking him to refrain from changing football’s rules to make the game safer. He also proudly reported that his own players were doing their bit to downplay their injuries.

“Should football in secondary schools receive a black eye, then the game in the colleges will certainly be affected,” he wrote. 

A lot of money was also at stake, even in football’s earliest days. Betting on games was unfettered in those early years (involving players as well as spectators), and “the financial stakes grew as the game became more popular,” explains Harrison. “Colleges competing for students saw the value of having a team 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.”

Concussion crisis redux

For many decades, specific concerns about football and concussions faded from public view, although general concern about player injuries led from time to time to the development of new equipment, such as “energy-absorbing helmets” in the early 1970s.

By the mid-1990s, however, football-related concussions were back in the news, particularly after the New York Times reported the troubling details of a concussion suffered by Troy Aikman, the Dallas Cowboy’s quarterback, in the 1994 championship game with the San Francisco 49ers.

Football is now experiencing its second “concussion crisis,” says Harrison. Whether this one will actually result in changes that reduce the risk of head injuries or just fade away like the crisis of 100 years ago is not yet clear, she adds: 

Better ways of reducing the risks of head injury may be found through high-profile collaborations of medical science and football corporations. But the long history of the concussion crisis tells us that, although the pursuit of fixes is well and good, proponents of fixes need 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. Steps must be taken to ensure that safety and honest interpretations of science drive the research that is done and the conclusions that are reached. …

We’ll see.

You can read Harrison’s blog post on the Somatosphere website. Her article in the American Journal of Public Health is, unfortunately, behind a paywall.