In July, 2015, Stephen Casper, a medical historian, received a surprising e-mail from a team of lawyers. They were representing a group of retired hockey players who were suing the National Hockey League; their suit argued that the N.H.L. had failed to warn them about how routine head punches and jolts in hockey could put them at risk for degenerative brain damage. The lawyers, unusually, wanted to hire a historian. A form of dementia called chronic traumatic encephalopathy, or C.T.E., had recently been posthumously identified in dozens of former pro football and hockey players; diagnosable only through a brain autopsy, it was thought to be caused by concussions—injuries in which the brain is twisted or bumped against the inside of the skull—and by recurring subconcussive blows to the head. In the media, C.T.E. was being described as a shocking syndrome that had never been noticed in sports outside of boxing. In essence, the legal team wanted a historian to tell them what science had known about head trauma, and when.
Casper, a history professor at Clarkson University, in upstate New York, had majored in neuroscience and biochemistry, worked in a lab studying dementia in mice, and earned his Ph.D. in the history of medicine from University College London. His dissertation explored the emergence of neurology in the U.K.—a history that included the study of shell shock and head injury in the First and Second World Wars. Casper agreed to work for the hockey players. He turned his attention to a vast archive of scientific and medical papers going back more than a century. In constructing a time line of how knowledge on head injuries evolved from the eighteen-seventies onward, he drew on more than a thousand primary sources, including medical-journal articles, textbooks, and monographs.
Reading the research in chronological order was like listening to physicians and scientists conversing across time. The dialogue spanned several eras, each charting rising concerns about head injuries from different causes—from railroad and factory accidents to combat in the World Wars, and from crashes in newfangled automobiles to the rise of college and professional sports. Casper found that physicians had begun to worry about repeated head injuries as early as the eighteen-hundreds. In 1872, for example, the director of the West Riding Lunatic Asylum, in England, had warned that concussions, and especially repeated concussions, could result in mental infirmity and “moral delinquency.” Other asylum doctors called the condition “traumatic insanity” or “traumatic dementia.” From that time onward, discussion of the long-term effects of head injuries in varying contexts, including sports, surfaced again and again. Physicians recognized lasting sequelae of severe head trauma, and sometimes expressed concern about the consequences of milder head blows, too.
Today, C.T.E. is the subject of furious controversy. Some of the debate has been stoked by researchers affiliated with the sports industry, who argue that we still don’t know for sure that head blows in football, hockey, soccer, or rugby can lead, decades later, to the dramatic mood problems, the personality changes, and the cognitive deterioration associated with C.T.E. These experts maintain that, before we rethink our relationship with these sports, we need scientific inquiries that meet highly rigorous standards—including longitudinal studies that would take fifty to seventy years or more to complete. In the meantime, millions of children and high-school, college, and pro athletes would continue butting heads on the field.
Casper believes that the science was convincing enough long ago. “The scientific literature has been pointing basically in the same direction since the eighteen-nineties,” he told me. “Every generation has been doing more or less the same kind of studies, and every generation has been finding more or less the same kinds of effects.” His work suggests that, even as scientific inquiry continues, we know enough to intervene now, and have known it for decades. It also raises important questions about how, and how much, old knowledge should matter to us in the present. If Casper is right, then how did we forget what’s long been known? And when does scientific knowledge, however incomplete, compel us to change?
According to Casper and other historians, the collision between sports and concussions began around the eighteen-eighties. American-style football, a descendant of rugby, was gaining in popularity at Ivy League colleges, and violence was fundamental to its allure. Players who wore stocking caps but no padding executed mass plays, such as the “flying wedge,” that led to savage clashes. Sometimes, young men died on the field. “Concern about concussions has a history in football as long as the game of football itself,” Emily Harrison, a historian who teaches epidemiology and global health at the Harvard School of Public Health, told me.
Football’s “first concussion crisis”—which Harrison wrote about in 2014—ensued after a study of Harvard’s football squad in 1906 reported a hundred and forty-five injuries in one season, nineteen of them concussions. In a commentary, the editors of the Journal of the American Medical Association (JAMA) singled out cases in which “a man thus hurt continued automatically to go through the motions of playing until his mates noticed that he was mentally irresponsible.” This behavior, they noted, suggested “a very severe shaking up” of the central nervous system, which, they argued, might have serious consequences later in life. Football, they concluded, was “something that must be greatly modified or abandoned if we are to be considered a civilized people.”
According to Harrison’s research, some leaders within the Progressive political movement had been calling for football’s abolition, on pacifist grounds. But that year President Teddy Roosevelt, the nation’s foremost mainstream Progressive, spearheaded the establishment of the Intercollegiate Athletic Association—a precursor to the National Collegiate Athletic Association. The association introduced reforms such as protective gear and the forward pass, which somewhat reduced bodily injuries and deaths. But the changes also introduced unintended effects. The incidence of concussions actually increased as players crashed into heavier body padding. As the First World War began, pacifism fell out of vogue, and football was valorized as a means of instilling manly values in boys. At the same time, ice hockey, which had first appeared in the late nineteenth century, became notorious for its violence, including brutal fistfights. Observers started calling for compulsory helmets in hockey in the nineteen-twenties. But the over-all trend was toward normalization: it became increasingly routine to hear about head injuries in sports. (The N.C.A.A. began requiring headgear in football in 1939; the N.H.L. wouldn’t mandate helmets—which can prevent skull fractures but not concussions—for hockey players until 1979.)
In 1928, in JAMA, a pathologist named Harrison Martland published the first medical report on punch-drunk syndrome. Martland, who was the chief medical examiner of Essex County, New Jersey, had performed hundreds of brain autopsies on people with head injuries, including a boxer. “For some time fight fans and promoters have recognized a peculiar condition occurring among prize fighters which, in ring parlance, they speak of as ‘punch drunk,’ ” he wrote; boxers with obvious early symptoms were “said by the fans to be ‘cuckoo,’ ‘goofy,’ ‘cutting paper dolls,’ or ‘slug nutty.’ ” Drawing on his own investigations and those of his colleagues, Martland concluded that the condition probably arose from single or repeated head blows which created microscopic brain injuries. With time, these small injuries would become “a degenerative progressive lesion.” Mild symptoms manifested as “a slight unsteadiness in gait or uncertainty in equilibrium,” he found, while severe cases caused staggering, tremors, and vertigo. “Marked mental deterioration may set in, necessitating commitment to an asylum,” he warned.
In his research, Casper looked deeply into Martland’s work. Impressed by its quality, he found that the pathologist had begun with a wider inquiry into brain injury, then had turned to the sport of boxing as an illustrative case for the hazards of head trauma. In Martland’s time, it was clear that boxers weren’t the only athletes in danger: another researcher, Edward Carroll, Jr., noted that “punch-drunk is said to occur among professional football players also,” and urged officials to make it clear to laypeople and athletes that “repeated minor head impacts” could expose them to “remote and sinister effects.” (Today, leading researchers believe that repetitive subconcussive hits—impacts that jar the brain but don’t cause symptoms—are a major cause of C.T.E.) Martland’s work was a widely publicized landmark. In 1933, the N.C.A.A. released a medical handbook on athletic injuries, written by three leaders in the emerging field of sports medicine—Edgar Fauver of Wesleyan University, Joseph Raycroft of Princeton, and Augustus Thorndike of Harvard—which cautioned that concussions “should not be regarded lightly,” and noted that “there is definitely a condition described as ‘punchdrunk’ and often recurrent concussion cases in football and boxing demonstrate this.”
As part of his expert-witness research for another lawsuit—Gee v. N.C.A.A., the only sports-concussion case to complete a jury trial—Casper obtained proceedings from the annual N.C.A.A. conference held in December of 1932, several months before the medical handbook was published. At the meeting, Fauver, the Wesleyan doctor, spoke about the risk of long-term brain damage: “As a medical man, it is perfectly obvious to me that certain injuries that seem to be rather mild when they occur may show up five, ten, fifteen, or twenty years later, and become very much more serious than first expected,” he said. “This is particularly true of head injuries.” Fauver cited the dangers of both blows in boxing and “repeated concussions in football.” Twelve years later, in 1944, another team physician wrote in the N.C.A.A.’s official boxing guide that, while the punch-drunk condition wasn’t common in amateur boxers, cases had been known “to occur among wrestlers, professional football players, victims of automobile or industrial accidents, etc.”
By the fifties, punch-drunk syndrome was being described as dementia pugilistica and chronic traumatic encephalopathy. At that point, Casper told me, “there was a clear consensus that repeated concussions produce both acute and long-term problems.” In a 1952 journal article, Thorndike, the Harvard physician, reviewed “serious recurrent injuries” across college sports. He advised that athletes who had more than three head injuries, or who suffered a concussion that resulted in a more-than-momentary loss of consciousness, should avoid further contact sports altogether. “The college health authorities are conscious of the pathology of the ‘punch-drunk’ boxer,” he wrote.
Casper’s historical work, begun in 2015, painted a clear picture: for at least seven decades, if not longer, many prominent physicians and sports organizations, including the N.C.A.A., had been well aware that concussions from a variety of sports could cause cumulative, crippling brain damage. “People who wanted to know could know,” Casper told me. “People who wanted to warn could warn.” The truth continued to be acknowledged as the twentieth century drew to a close. “The blow is the same whether it’s in boxing or in football,” a physician with the American Medical Association told Congress, at a 1983 hearing on boxing safety; cumulative nerve-cell damage from repeated impacts, he went on, “may lead in some people to the punch-drunk syndrome.” As an example of a serious football head injury, the doctor mentioned former Giants star Frank Gifford, who had taken a season-long hiatus from the game after being “knocked cold for twenty-four hours.” Gifford would later be diagnosed with C.T.E. after his death, in 2015.
The Forgotten History of Head Injuries in Sports
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