Brain Bucket: a Social History of War, Football, Helmets, and Head Injury
A series for the playoff season
Standardized head protection appeared on the football field and the Western Front at the same moment in 1915.
Our brains have never recovered.
“How many fingers am I holding up?” the team doctor asked, holding up just one finger. It was a hot Friday night during the first week of September 1988. Patrick, our starting quarterback, had just been helped off the field after a vicious hit that left him momentarily unconscious.
Patrick (not his real name) got the answer right, so he was told to wait on the bench. However, a moment later he expressed confusion to me about which quarter of the game this was, and how we had scored the number of points on the board. Upon seeing that Patrick was having memory issues, the doctor had him transported to the emergency room.
The next Monday afternoon, our head coach gave a speech about playing through the aches and pains of football. He singled out Patrick in street clothes, explaining that the team physician had instructed our teammate not to practice or play football for at least a week.
“You have to decide when you are ready to lead again,” Coach intoned, giving lip service to the serious nature of Patrick’s injury. Then, in the very next breath, he made it crystal clear that Patrick should want to play this Friday, when playoff hopes would be on the line.
“It’s gonna be a war,” our coach said. “I need my captains in the fight.”
In 2005, Sergeant James (not his real name) was sitting in the rear seat of an unarmored cargo truck on its way to Tal Afar from Mosul when a roadside bomb struck the convoy.
“It felt like someone kicked me in the chest and my ballistic plates literally slapped my chest,” he explains. “The truck in front of me took the majority of the impact,” killing the driver. Although Sgt. James and his driver survived the blast, he was knocked unconscious for a moment, and then blinded for several minutes upon awakening. He suffered headaches for days afterwards.
These are classic symptoms of a minor traumatic brain injury, or mTBI. Yet like millions of veterans before Sgt. James, his mTBI went undiagnosed and untreated “because we didn’t do that in 2005.”
Gotta play through the hurt, son, it’s a war.
“The military wasn’t ready for [improvised explosive devices, or IEDs] and surely not willing to hand out disability checks for the thousands of troops coming in contact with high explosives,” Sgt. James says. He estimates that “there are probably 100,000–200,000 others that have never been diagnosed.” Nevertheless, by 2006 an epidemic of mTBIs forced military physicians to include a “concussion protocol” in their triage systems.
Head injuries account for 20 percent of all wounds on all battlefields since 1914. Whereas the head makes up just 9 percent of our human bodies, blast injury has accounted for about half of all wounds sustained in Iraq, with most of those injuries happening to soldiers’ heads. A 2009 federal study of nearly 4,000 veterans of the war in Iraq found that almost one in four of the sample population had a “clinician-confirmed” case of mTBI. Separately, a 2008 study found strong links between TBI and posttraumatic stress disorder (PTSD) as well as depression.
These findings have challenged a century of conventional wisdom about combat trauma. Until the last decade, virtually all behavioral and cognitive issues in war veterans were ascribed to either psychological wounding or moral inadequacy. We now know that many of these invisible injuries occur through physical blows to the brain.
Put simply, modern war destroys the brain. So does American football. Both activities produce TBI in abundance. They also both produce Chronic Traumatic Encephalopathy (CTE), a condition linked to behavioral problems, personality changes, cognitive deficits, higher risk of suicide, early death, and more.
The damaging effects of American football and war with high explosives are so similar that two of the leading institutions in our scientific understanding of CTE, Boston University and the Department of Veterans Affairs, have worked together in recent years. Their collaboration has identified hundreds of dead soldiers and football players whose brains share a similar pattern of brown, dust-like scarring — deposits of tau protein dislodged from nerve axons and clumped around blood vessels in the white matter of the brain.
“The average age of death among all players studied was 66,” they announced in 2017. “There were 18 suicides among the 177 diagnosed.” Examining the brains of more than 200 cadavers, they “found evidence of a brain disease linked to repeated head blows in nearly all of them, from athletes in the National Football League, college and even high school.”
While the sample was hardly random, the fact that so many families suspected CTE and had their fears confirmed indicates a profound underlying relationship between the game and the disease. The same is true for families of military veterans.
Much remains unknown about the scale of the problem. What we do know, as revealed by Boston University’s Chronic Traumatic Encephalopathy Center, is that the disease seems to be especially damaging in youth. Players who are between the ages of 10 and 12, when brain development is at a peak, are believed to be the most vulnerable. CTE may even explain many later encounters with the criminal justice system. Playing on the gridiron before the age of 12 “increased the risk of problems with behavioral regulation, apathy and executive functioning by two-fold and increased the risk of clinically elevated depression scores by three-fold,” BU’s School of Medicine explained in September 2017. “The increased risk was independent of the total number of years the participants played football, the number of concussions they reported, or whether they played through high school, college, or professionally.”
This crisis is actually much older than our understanding of CTE. The American Academy of Pediatrics first recommended that children not play tackle football until high school in 1956. Millions of children have done unknown damage to their brains since then; some of these are better-known than others.
Aaron Hernandez, a former NFL star who committed suicide in prison at the age of 27, was diagnosed with CTE after his death. It is very likely that he developed the condition before his college or professional career, and it could very well explain his outcomes: severe depression, a sociopathic disregard for life, inability to judge second- and third-order consequences, suicidal ideation. Hernandez died a pariah, judged for bad morals, but his talent on the field may have been his real curse. Would Hernandez have ended up in the same place without football? We have no way to know, yet the question demands to be asked.
Of course, combat has different mechanisms of injury than football, even if they produce similar physical trauma to the brain.
As the shock wave (“overpressure”) produced by high explosive detonation passes through a complex material medium, each new layer of that material (skin, skull, meninges, cerebrospinal fluid, gray matter, white matter) absorbs the impact differently, flexing and distorting. This shearing effect dislodges the tau proteins from their nerve axons, producing the characteristic brown “dust” in the white matter of the brain.
Skull fracture is hardly necessary for this to happen. A blast wave passes right through bone and makes the brain ripple inside it like gelatin in a mold, focusing the energy of the blast inside the skull. This is a well-understood phenomenon in blast physics, a hallmark of the supersonic shock wave that is only produced by high energy, i.e. modern, explosives — the weapon that has dominated every major battlefield since 1914.
The forces at play in football are less energetic, but just as debilitating. Even if a player never suffers a concussion in the course of their football career, all players are exposed to the repetitive impacts of tackling and blocking to some degree. Many years of playing football can thus damage the brain cumulatively, producing the same effects as high explosive blast waves, with similar effects on cognition and morbidity.
Football is a “contact sport,” after all, and it is this contact which inevitably causes injury to the brain. As described through Newtonian physics, the brain is still in motion whenever the skull stops, crashing against the interior, rebounding to strike the skull on the opposite side, bouncing back and forth. A player need not take a direct hit to the head to suffer a brain injury; as I recall, Patrick, our high school quarterback, was blindsided in the body, not the head, and tackled hard onto the ground.
Underlining the role of repetitive blows in CTE cases, the condition was first discovered in boxers. Described as “punch drunk” syndrome in 1928 and then “dementia pugilistica” in 1937, the mechanism of the injury was not understood by science until 2003, just before Sgt. James went to war. At that point, the effects of high explosive warfare had been studied for nine decades without ever detecting the disease. Similarly, brain damage in American football had also been the subject of intense scientific inquiry and sports engineering, yet CTE had escaped notice there, too.
Which is not to say that nobody noticed there was a problem, or that no one tried to do something about it. Indeed, during 1915, the world’s armies and the American gridiron experienced simultaneous revolutions in brain safety engineering. This should be no surprise, for by that point the American game had grown up alongside the new way of war that was manifesting on the Western Front, in direct parallel, for nearly half a century. This is not a mere coincidence: American football is a conscious cultural reenactment of early mass fire warfare. We call the area around the football “the trenches” for very good, very grim reasons.
Next Sunday: why tackle football reflects the values of mass fire warfare