Public awareness of the long-term effect of head injuries sustained in competitive sports, including but certainly not limited to collegiate and professional football, has increased significantly in the past decade. The highly publicized National Football League (NFL) federal court litigation has transitioned from the sports section to page-one treatment in multiple news media and as a source of widespread commentary. This article will focus upon the lesser-known historic events in which physicians and specialists focused upon brain injury both within and outside the context of modern athletics.
More than two centuries ago, the British surgeon John Hunter determined that injuries to the brain by mechanical means could be divided into three specific groups: concussion, compression, and brain wounds with loss of substance. Recognizing that the type of injuries sustained within each sub-group could produce symptoms much like the others, Hunter also focused upon the significance of concussion: “When there is depression of bone or extravasation, the symptoms of concussion are lost, though it may be at the bottom of it all.” Hunter (1841).
In the United States, the advent of modern study of brain injury is often attributed to Harrison Martland’s study of boxers published in 1928 by the Journal of the American Medical Association. A pathologist, Martland introduced the term “punch drunk” to describe a series of complex symptoms that appeared to result from repeated blows to the head. According to Martland’s research, nearly 50 percent of the boxers that he examined exhibited such abnormalities “if they kept at the game long enough.” H.S. Martland, Punch Drunk, 91 JAMA 1103–07 (1928). This seminal work, published more than 85 years ago, is often considered the first to link sub-concussive injuries and “mild concussions” to degenerative brain disease.
Fifteen years after Martland’s study was published, the British journal Lancet reported a study by Holbourn in which the author described the mechanics of brain trauma in the following manner:
Damage to the brain is a consequence, direct or indirect, of the movements, forces and deformations at each point in the brain. The movements, forces and deformations are not independent; so it is sufficient to express everything in terms of deformations. These are worked out with strict adherence to Newton’s laws of motion, but with approximations to the constitution of shape of the skull and brain. Hence further advances can only come from making better approximations.
A.H.S. Holbourn, 2 Lancet 438 (1943).
The Master Complaint filed in the National Football League litigation includes a litany of studies, conducted both here and abroad, that track the developing focus on head injury in sports. Among the reports, research and studies listed are the following:
- Research by Drs. Serel and Jaros in 1962 addressed the heightened incidence of chronic encephalopathy in boxers, describing the symptoms as a “Parkinsonian” pattern of progressive decline.
- Studies published in 1969 and 1973 recommended that any concussive event with transitory loss of consciousness should require the removal of a football player from play and require follow-up monitoring.
- In 1973, a potentially fatal condition known as “second impact syndrome” was identified (although not so named until 1984). The syndrome was marked by re-injury to an already-concussed brain, precipitating swelling that the skull is unable to accommodate.
- In 1986, Dr. Robert Cantu of the American College of Sports Medicine published Concussion Grading Guidelines, which he later updated in 2001.
These studies and others gave rise to the diagnosis of “chronic traumatic encephalopathy (CTE),” a diagnosis associated with memory disturbances, behavioral and personality changes, Parkinsonism, and speech and gait abnormalities. Pathologists have identified findings on autopsy including atrophy of the cerebral hemispheres, medial temporal lobe, thalamus, and brainstem, among other clinical observations of CTE victims. Dr. Bennet Omalu is often given credit for first describing and identifying CTE, after he completed an autopsy of former NFL player Mike Webster of the Pittsburgh Steelers. League of Denial: The NFL’s Concussion Crisis, PBS (Oct. 8, 2013). Dr. Omalu’s findings are not unlike those of Dr. Martland’s “punch-drunk” fighters, first manifest by deteriorations in attention, concentration, and memory, often accompanied by disorientation, confusion, dizziness, and headaches. In CTE, symptoms progress and include lack of insight and poor judgment; even overt dementia may become evident. The most severe cases are accompanied by a progressive slowing of muscular movements, impeded speech, tremors, vertigo, and deafness. The final stages of CTE consist of overall cognitive dysfunction progressing to dementia and often full-blown Parkinsonism. Chronic Traumatic Encephalopathy in Athletes: Progressive Tauopathy Following Repetitive Head Injury, 68 J. Neuropathology Exp. Neurol. 709–35 (July 2009).
Beginning in 2001, International Conferences on Concussion in Sport have been held in Vienna (2001), Prague (2004), and Zurich (2008 and 2012). Each symposium has resulted in publication of a “Consensus Statement” representing a collaborative, international effort to define the symptoms of concussion and the current standards for diagnosis and treatment. In its most recent statement, the 4th International Conference on Concussion in Sport defined concussion as follows:
Concussion is a brain injury and is defined as a complex pathophysiological process affecting the brain, induced by biomechanical forces. Several common features that incorporate clinical, pathologic and biomechanical injury constructs that may be utilized in defining the nature of concussive head injury include:
- Concussion may be caused either by a direct blow to the head, face, neck or elsewhere on the body with an “impulsive” force transmitted to the head.
- Concussion typically results in the rapid onset of short-lived impairment of neurological function that resolves spontaneously. …
- Concussion may result in neuropathological changes, but the acute clinical symptoms largely reflect a functional disturbance rather than a structural injury and, as such, no abnormality is seen on standard structural neuroimaging studies.
- Concussion results in a graded set of clinical symptoms that may or may not involve loss of consciousness. . . .
Clearly, the early clinical findings by Dr. Martland have evolved with developments in modern medicine, but his essential diagnosis of “punch-drunk” fighters remains consistent with our most refined definitions of CTE and concussion. Understanding the early efforts of Hunter, Martland, Omalu, and others provides context to the still-evolving medico-legal issues contested each day in our state and federal courts.