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

Abstract

In the early 21st century, sports concussion has become a prominent public health 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 recent phenomenon, the crisis in fact began more than a century ago, as concussions were identified among footballers in the game’s first decades. This early concussion crisis subsided—allowing the problem to proliferate—because work was done by football’s supporters to reshape public acceptance of risk. They appealed to an American culture that permitted violence, shifted attention to reforms addressing more visible injuries, and legitimized football within morally reputable institutions. Meanwhile, changing demands on the medical profession made practitioners reluctant to take a definitive stance. Drawing on scientific journals, public newspapers, and personal letters of players and coaches, this history of the early crisis raises critical questions about solutions being negotiated at present.

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

“The only serious injury I received was in the game with Harvard in 1883,” typed former Penn footballer William Harvey in 1894, “when in a scrimmage behind the goal I was knocked insensible, but 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 college 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 reply. “During the summer following,” it continued, “I was sick with blood gathering in the head and threatened with congestion of the brain, my illness being attributed by the Doctors to the above incident.”¹

Harvey had returned to play the following year, 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. “Under present rules,” he posited, “it would be almost impossible for an injury to happen to a player, such as I experienced in ’83.”¹

Harvey’s hope that the problem of head injury in football could be solved with technical reform is one shared by many now, more than a century later, as a “concussion crisis” emerges in American sports. Referring to the problem as a “silent epidemic” in a 2003 report to the US Congress,² 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, among which football is the greatest contributor.³ One study of CDC data collected in 2005–2006 estimated that 55 007 concussions occur each year in organized high-school football alone.⁴ Another calculated the concussion rate during participation in football practice and competition to be 0.47 in high-school football 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, but it is clear in the 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 head injury over the past decade, as have claims that concussion in children is more severe, with longer recovery time.⁶ As awareness of the prevalence of concussion across the population swells, debates about 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 down data about 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 between concussion and a degenerative brain condition called chronic traumatic encephalopathy,⁸ and both have partnered with prestigious medical institutions to study prevention, diagnosis, and treatment.⁹

Contrary 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. It emerged more than a century ago, in the very first decades of football. At that time there was ample evidence that concussion occurred frequently, and ample reason to believe that concussion could have 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 made the concussion problem worse. The early concussion crisis subsided because concerted work was done by football’s supporters to shape and reshape public acceptance of risk: 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 good medical practice left early 20th-century physicians reluctant to take a uniform and definitive stance.

This early concussion crisis in football raises critical questions about 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 problem 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 among young men playing football in elite colleges is now a serious problem of public health.

AMERICA'S MOST DANGEROUS PASTIME

Years before the first medical study of football 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’s 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, one 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 day’s game.”¹³ More matter of fact, another commented that “it behooves the promoters of the game to hold 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 city, but the message was clear. “The present Rugby game of football as played in this country is a very risky pastime,” The New York Times proclaimed, carrying “nearly the same risk that a soldier [assumes] on the battle field.”¹⁵

In these early days, college 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 most wore only a stocking cap for decoration and team identification.

Football was one among many team games that emerged in the years following 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 once the frontier was lost, to a compulsion to simulate wars looming on past or future horizons. Others argue that American sports emerged from a craving for community in the ever-growing city of strangers, or a deep social anxiety about health and fitness that came with changing demographic patterns at the end of the 19th century.¹⁶ The reason given at the time was stated as though it 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 set football apart from other team 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 violent nature.¹⁹ Charles Eliot, president of the university, led the opposition. “Worse preparation 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 apparently recovered from in good measure, but which are likely to prove a handicap to the victim in later life.” Beyond the physical threats, he believed that “the main objection lies against its moral quality. . . . The common justification offered for these hateful conditions is that football 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 stance was unequivocal:

If a college or university is primarily a place for training men for honorable, generous, and efficient service to the community at large, there ought not to be more than one opinion on the question whether a game, played under the actual conditions of football, and with the barbarous ethics of warfare, can be a useful element in the training 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 “one thing is certain, and that is that our popular college sport must be modified so as to permit of playing without danger of life and limb.”²¹ In the Boston Globe, a footballer stated that he did “not think the objections that have been raised to football are strong enough to lead to its abolition as a college game. There are some things radically wrong about it, but we can correct them.”²²

Over the last 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 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 committee set to work saving the game through persuasive selection of evidence, technical reform, and pressure on college administrators and faculty.²³

In one effort, 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 “only serious injury” that had him “knocked insensible” and “sick 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 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 head injury has been blatantly crossed out in crayon. In the published Football Facts and Figures, Harvey’s remaining testimony reads only this:

Philadelphia, April 20, 1894

I consider football one of the grandest games that is played. My experience on the football field has stood me in good stead and has taught me self-possession and the faculty 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 fellow men.

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

Yours very truly, W. S. Harvey²⁶

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

As evidence like this was selectively silenced and broadcast in the interest of the game, a series of rule reforms was being 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 up the game, making fouls more visible to referees and reducing momentum plays. They also made the game more interesting for spectators to watch.

The watchdogs of player safety were not 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 first reforms was more 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 College 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 against the game from its medical standpoint.” Their article, systematically documenting the nature and number of injuries sustained by the team over the 1905 season, highlighted one injury in particular that had been hiding in plain sight: concussion of the brain.

The concept of brain concussion had been traveling through common and medical usage for centuries. As early as the mid-16th century it had been defined 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 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 as the result of an injury, the central nervous system has received a very severe shaking up.” The doctors could not extrapolate from their small, one-season sample to make strong claims about the long-term consequences of concussion, and neurologists had not studied football injuries in particular, but those tasked with judging evidence for policy and practice took a stance. The American Medical Association reported that, although

there was a time when it 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 opinion at the present time.³³

Head injury from other causes had provided evidence of concussion’s risks: train collisions, frequent in the late 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 made 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 one season alone there had been no less than 19 concussions, and although some football advocates had guessed that only 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 especially to close competition in big games.”³⁵ The public received word of the doctor’s “astonishing statements with reference to the frequency and nature of the injuries sustained” from the popular press, which noted that “the most surprising fact he states is with respect to brain concussions.”³⁶ The American Medical Association picked up on this extraordinary statistic, too, commenting that

perhaps the most serious feature 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 20 years, as the cause of death or hospitalization. The shock with the statistics of the 1906 paper was not that concussions were happening, but that they were happening in nearly 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 frequently noticed by a surgeon from the side lines before 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 almost invisibly in the noise and action of a game. The concussion crisis had begun.

VISIBLE ENOUGH TO COUNT

The turn of the century was a time of heightened awareness to injury. The industrializing workplace was a space where accidents inspired worker’s 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 too little attention to head injuries. “We all know that any 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 most obvious skull fracture for the “subsequent suffering” seen in victims of head injury. Treating observable injuries like fractures with rest, symptom management, and reduction of stimulation might, he postulated, also care for invisible injuries in inaccessible parts of the brain:

Every case of recent head injury, however trivial it may appear, should, we believe, be treated with the greatest consideration, lest damage to hidden and important structures escape our attention, thus leaving a foundation for future trouble which too often is irreparable. . . . Unless our range of inquiry is sufficiently comprehensive to take in all possibilities, deeper injuries may remain, to be followed by headache, epilepsy, or even insanity.⁴⁰

But lack of medical attention was not merely the result of carelessness. Around the same time that football was becoming popular in American colleges, the profession of medicine was striving to gain new legitimacy as a scientific endeavor. Where clinical observation had once been sufficient proof of harm, a new demand was emerging for experimentally supported, evidence-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 back their prescriptions.⁴¹ These kinds of scientific evidence were exceedingly difficult to extract from the occult regions of the brain and the hidden processes linking brain and behavior over time.

Physicians were all too aware of their inability to produce visual evidence. Injury, they conceded, could occur in the brain without visible damage to the head. But there were serious constraints to proving this in a living person. For injury hidden beneath skin and bone and inches of seemingly unaffected brain tissue, there was no easy means of detection, no “rational surgical procedure based on science and common sense” as there was for fractures of the skull and visible tearing of the brain.⁴² New nerve staining techniques only allowed 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 understand not only the injury itself, but also long-term psychological effects. There 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 nutrition and thus produce psychic disease, at once or after a long interval.⁴⁵

Others hypothesized that concussion changed the brain’s molecular composition. “With or without material injury,” one wrote,

the shock 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 period between traumatic injury and behavioral symptoms proved a barrier to building an evidence-based theory. The mechanical theory was not

sustained by the facts found in many cases, for the reason that the surgeon and pathologist have failed to show a state of facts. If such lesions did exist they would have 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 conditions.”⁴⁸

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

generally located in the surface of the brain beneath the contused part, but frequently also deep down around 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 after injuries to the head,” one 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 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 prove when not everyone hit in the head became drunk or insane. Some thought head injury merely acted as a mediator, exacerbating preexisting conditions and speeding up their course. Others thought the head injury could only act as a cause in people who were predisposed by hereditarily weak constitution. To control for competing ideas the researchers required that, to be counted as a case, a corpse must have been in good health before the concussion event and that “the symptoms must be of distinct evolution and must come on within a reasonable time.”⁴⁹ This limited what kinds of effects could be seen, counting out side effects or symptoms that did not present until later 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 about 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 But, 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 Large. Cases of Concussion of the Brain Increase.” 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 it led by a much higher proportion than in either of the two 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 even as medical authorities wrote more and more confidently about the links between nonfatal concussion and mental disorder. By 1911 a Journal of the American Medical Association (JAMA) article, summarizing the work of a number of German 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 developed the same outcomes, it was distinguished that

injuries which produce an extensive, diffuse shaking up or shattering of the brain 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 around a mechanism of diffuse 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 by no untoward, immediate symptoms,” the article noted, continuing:

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 distractable. 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.⁵⁵

Although the classification of this psychosis was not entirely clear, the authors were certain that “those who knew the individual before the injury will invariably notice” the change.⁵⁶

The JAMA report concluded with a clear exhortation that the medical community treat concussions not merely as acute injuries, but according to the “effects the injury will have on the patient’s future life.” These injuries had the potential to rob the “faculties which bring about an adjustment between individual and environment,” and if the injury was not 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 by this injury?’”⁵⁷ The fact that there were instances in which there was liability law–induced malingering did not detract from the real cases, and physicians were urged to take seriously “the importance of this class of mental disturbance for the general practitioner, and especially 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 after the injury, and that according to Ziehen, the traumatic psychoses form 3 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

head injuries may have a lasting deleterious effect on the individual that while a cross section at any particular point may not show any gross pathologic findings, yet 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 But no studies were done on football until much later in the century.

INCENTIVES TO DOUBT

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. Certainly, there were financial stakes in football. The sport emerged in an era of unfettered betting among both players and spectators. One paper 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 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 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. 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. As 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 countenance some of the things they decided to discard a half dozen years ago.⁶²

But financial interests were not alone in sustaining the game. Football also 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 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. It appealed to anxieties about America’s relative lack of fitness, and appealed to a culture 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 make the game more “scientific,” appealing 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 after reforms repeatedly failed to remove the risk. Public claims were made that “skillful players are less liable to injuries. . . . Playing to the point of exhaustion should be avoided. Proper padding also 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 role was to not just educate in academics but also to turn boys into men. Although a few university 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 man can play football under [Coach] Harlow without being a better man when he is through. By this I do not mean physically but in every way 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 damage the reputation of the squad, but it also meant upholding the game. “We must have loyalty!” Coach 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 organization.”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 also nationally. “As I told you,” a member of Wisconsin’s Interscholastic Athletic Association wrote to Harvard’s Dean Delmar Leighton in 1935,

I want no member of the football staff writing for the papers. I feel our task should consume all of our time and brains and with no intended criticism of the past, I feel that a measure of dignity that is associated with the name of Harvard is lost in so writing.⁶⁹

Even members of the Rules Committee steered clear of the public in protection of the game. One important and well-respected committee member, William Langford, became so upset at the internal handling of player safety that he resigned. “There is not the slightest doubt 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 director. But instead of speaking out about the incongruity, he left quietly. “I have purposely kept the matter quiet because publicity of any sort would be harmful to the game,” he confided in closing.⁷¹

One of the great conundrums of the manly ideal in football is that it came to require the participation of young boys. In its early days, children had been excluded. “Football is not a sport for boys by any means, and young men ought to be strong in the first place and be assured of good coaching in the second before they tackle it,” one paper reported the common belief.⁷² But within 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, Principal Chamberlain of Milwaukee’s Riverside High School wrote to Dean Delmar Leighton of Harvard College urging that the rules not be changed to make the game safer. He counted his pupils among the “men who are playing football” and downplayed the absolute number of injuries. The injury rate in high schools, he calculated, was only about one fifth of that in the colleges. By this accounting, he concluded that made “high school football a good deal safer than that in college when we consider the number of players engaged.”⁷³ The image of the high-school game was “as much to the interest of colleges as it is to the high schools,” he warned. “Should football in secondary schools receive a black eye, then the game in the colleges will certainly be affected.”

Above 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 can be good parents by ensuring their children wear helmets. Others on the site reinforce the cultural idea that putting young children in warrior-like 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 body as well as rule reform. But 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 we should consider at our meeting this winter 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 Committee will make 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 so that the helmets no longer shattered as easily as the initial incarnations. Early concern focused on preventing skull fracture more than concussion,⁷⁶ but growing interest in injury prevention eventually brought greater attention to injury to the head and spine more generally. In the early 1970s air bladders were added to “energy-absorbing helmets” and four-point chin straps were required at the collegiate level after 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 before the 1994 Super Bowl that star quarterback Troy “Aikman’s concussion has focused attention 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 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-end helmet design 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” chin 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 not advanced much beyond rest, reduction of sensory stimulation, and symptom management—similar recommendations to those available in the early decades of the 20th century when the crisis was first documented. Research and response have accelerated. Findings on the compounded risk of multiple head injuries have influenced official recommendations about return-to-play decisions.⁸⁰ Most states have passed legislation requiring education, removal of a concussed athlete from the game, and physician clearance before returning to play.⁸¹

And yet, through ongoing tinkering with equipment and reforms, much continues to be 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’s warnings about the risks inherent in tobacco smoking, some saw this as a success for public health as well. With time, 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 not the responsibility of the company or the public who permitted the product to be sold.⁸³ The NFL’s labeling of locker rooms with posters likewise individualizes responsibility, institutionalizing the idea that it is the player’s responsibility to recognize and assume the risk of concussion. Current National Collegiate Athletic Association guidelines, too, 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 make this career- and team-changing decision in the face 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 up through the ranks—not only the few children who will ever play professionally but also all the children who never will. All are subjected to known risks, with the approval of their watching friends, parents, and teachers.

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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.⁸⁵ 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.

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

This was acknowledged among even the very earliest discussions about American football’s concussion crisis. “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,” 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 we are to be considered a civilized people, and if our universities are to be considered centers for influence for good.

The realities of the game should be its death knell, the writers argued, unless authorities “fear unpopularity more than they dare to be right.”⁸⁷