From ‘Punch Drunk’ to CTE: How the Sports World Learned to Ignore Brain Trauma

Ever since Bennet Omalu published a pathology report describing the neurodegenerative disease chronic traumatic encephalopathy (CTE) in the brain of deceased former National Football League player Mike Webster in 2005, journalists, sports organizations, Congress, and even Hollywood have grappled with what the risk of long-term brain damage means for American football.

Along the way, the general consensus has been that CTE is a new problem. Granted, some journalists have noted that the disease was first described in forensic examiner Harrison Martland’s 1928 publication “Punch Drunk,” while others have pointed to a 1937 coinage of “dementia pugilistica.” Beyond that, however, it has been a perceived truth that few in the past knew anything about the disease.

But this perceived truth is a cultural myth.

I am a historian of neurology and neuroscience. For the past five years, I have been researching and writing a book about the cultural history of brain injuries. The record is clear: CTE is an old problem, and people in sports and medicine alike have known plenty about it for a very long time.

So why does this myth exist? There are many reasons. Powerful sporting organizations over many decades found ways to feed it. Universities do not wish to admit that they have harmed – and are harming – their own students. Arrogant doctors dislike being confronted by the evidence of their own past callous disregard. Even now, fans of football tend to want to deny the health implications of recurrent hits to the head or the fact that football helmets historically have been superbly designed as concussion delivery systems.

Yet beyond these reasons is another important facet of sport in general that so often goes disregarded: for every winner, there must be a loser. Losers in sport sometimes become losers in life. American culture celebrates winners and winning. It rarely tells complex stories about why losers became losers. Indeed, to focus on the losers and what happens to them after they vanish from sports is to reveal a preference for the company of sports losers rather than winners.

To understand how this stigma around losing and brain injuries has played out in the past – and how it parallels today’s debates over football – look no further than the history of intercollegiate boxing.

Last year, I came across a faculty report in the archives of the University of Illinois, Champaign-Urbana. Undated and plainly buried out of sight from the day it was written, it was obvious that it had been prepared in the late 1940s. The hint to its existence had emerged in boxing rulebook drafted by the National Collegiate Athletic Association. The report was clearly an important document. Few such sources now exist that shed much light on both brain injuries and sporting history.

In the period that the report was prepared, the neuropathology of brain injuries was hotly debated. Some authors contended that concussions did not produce brain damage. Others said that autopsies showed concussions left signatures behind in the tissues of the brain.

As those debates raged in science and medicine, boxing was reaching its peak popularity in America. By 1932, the NCAA had begun sponsoring national championships. Fans, many of them trained in boxing during World War I, made amateur and professional bouts popular. And the sport continued to grow after World War II.

Despite its popularity, boxing was extremely controversial. The professional sport routinely produced muck-raking journalism. Deaths of amateurs and professionals resulted in public calls to make the sport safer or to abolish it. Fear of insidious diseases – brain diseases – had also begun to shape public denunciations of the sport.

Boxing fans did not want to hear it. Their retorts often took the form of stigma and victim-blaming. The victims of such diseases, so their reasoning went, had no one to blame but themselves. The victims were sluggers. They were badly trained. They were probably homeless derelicts, like those Earnest Hemingway had caricatured in his 1925 short story “The Battler,” now regarded as one of his finest artistic contributions.

Comedy was another avenue of dismissal. In 1951, the comedian Red Skelton introduced a routine in which he pretended to be punch drunk boxer “Cauliflower McPugg,” basically mocking physically and mentally disabled people. Another pug named “Slapsie Maxie” Rosenbloom became famous for his comic routines, which included a funny walk that mimicked Parkinsonism.

Stigma even extended to the American legal system. So shameful were the legacies of head injuries for individual boxers that they sometimes brought libel suits against those who even suggested the illness in print. In 1956, a court heard Stillman v. Paramount Pictures, in which a gym owner sued the studio for implying that punch drunks could be found frequenting his training facilities.

The University of Illinois report thus appeared in a specific cultural moment in American history when boxing was more popular and controversial than ever. It also was relatively new to college sports. At the time, 32 universities had intercollegiate boxing, with approximately 1,760 students participating. Fifty-five schools had intramural boxing programs, with approximately 5,680 students participating. Spectatorship was growing rapidly, and there was real money to be made – provided people believed boxing could be safe for college students.

Proponents of boxing, the report’s authors began, argued that boxing was a heroic combat sport. It instilled good values, courage, and stamina in students. It taught students to defend themselves – taught them that the world was not a nice place and that their fists could change that. It taught them to face their opponents.

By contrast, the report noted that boxing’s opponents said that it was bad for the physical and mental well-being of students. People with concerns about boxing sometimes abhorred the sport’s inherent violence and spoke particularly of the “cumulative damage to mental processes caused by concussions of varying severity.”

Related: Difficulty with Speech, Memory and Behavior May Be Signs of CTE

Because of the furor attached to these arguments, the report investigated whether boxing should be encouraged at the collegiate level. Crucially, the report’s authors sent out surveys to neurologists and psychiatrists to ask them for their views. They asked other university authorities. They queried athletic directors for their opinions and sought guidance from directors of health services in other universities.

About half of all athletic directors surveyed thought boxing was excellent for physical conditioning and teaching self-defense. Health service directors were ambivalent about the sport’s safety. Strikingly, 46 neurologists and psychiatrists responded to the survey. The doctors reported seeing cases of mental impairment attributable to boxing. More than three-quarters of the doctors agreed that “repeated blows to the head over a period of years can cause gradual changes in mental patterns of the individual.” Twelve schools attributed boxing to cases of “punch drunkenness” in their institutions.

Although the neurologists and psychiatrists had seen boxers of all kinds, professional and amateur, the report’s authors nevertheless accorded them significant expert weight. They concluded that boxing should not be included in the extracurricular activities of an educational institution – or at least not at Illinois. They noted that two Illinois students had died because of boxing, one immediately from a knock-out and the other in hospital hours after a bout. They wrote that injuries in the sport were badly reported, giving as an example that one university had reported no serious injuries, even though a neurosurgeon had reported performing an emergency operation on a student boxer from that same university “to remove a blood clot and ligate one of the blood vessels supplying the brain.”

But death was not the primary problem. The report’s authors took the view that the more serious problem was the mental disturbances that “follow the accumulative effect of repeated blows to the head.” They remarked that such injuries also could occur in accidental falls, automobile accidents, and street fights, and that the illness was referred to scientifically as “traumatic encephalopathy or dementia pugilistica.” And they were troubled by the fact that that “remote symptoms develop insidiously or slowly,” allowing students to go through college “engaging in boxing without showing much evidence of changes in personality, mental patterns, concentration, etc., and in a few years after they have finished may definitely present these symptoms of mental degeneration.”

Writing that “the effects of head blows are cumulative and are not recognized in early stages,” they observed:

Some of the athletic directors believe that the term “punch drunk” is a newspaper coined phrase which does not actually exist. It is fortunate that they have not had any students with this disturbance. It is most unfortunate if such cases of dementia were developing, but in the early stages when they were not recognized, and those students allowed to continue boxing, added insult to injury.

The Illinois report clearly shows that scientists and doctors in the 1940s recognized that blows to the head could give rise to CTE. It shows that knowledge of these facts was widespread. Yet this knowledge did not, on its own, lead college sports authorities to abandon boxing.

The high-profile death of the University of Wisconsin student and boxer Charles Mohr in 1960 is often cited as the end of boxing as a major college sport. A few weeks after Mohr died from a brain bleed suffered in a national championship fight, the school dropped the sport, and the next year the NCAA did the same. Given that at least 54 college students died playing college football from 1931 to 1965, however, it’s hard to argue that the people in charge of university athletic departments viewed fatalities as a reason to stop playing dangerous sports.

Instead, it’s likely that college boxing was done in by stigma. There had simply been too many examples of boxers whose personal problems had been publicly attributed to their vocation. Even the sympathetic portraits of suffering boxers that began to appear – on TV, in film, and in magazine exposes – contributed to this particular distaste for losers.

Colleges and universities educated young people’s brains. That was their mission. Schools did not, and certainly could not, become known for damaging brains. Moreover, college graduates were seen as society’s winners. The stigma of losing a collegiate boxing contest was not of any real concern – but becoming a loser in life as a result of participating in college boxing most certainly was.

As boxing lost cultural ground to football in the decades following its collegiate peak, the controversies it inspired slowly died out, too, appearing only now and then when globally famous fighters like Muhammed Ali revealed their mental and physical troubles. It took Webster’s story to bring those same controversies to football – even though generations of college football players also had been exposed to repetitive blows to the head.

Since 2005, some in the medical profession have argued that undue media attention has created public hysteria about concussions in sports and the acute and long-term sequelae associated with brain trauma. Former heroes of the gridiron who develop problems are questioned about their personal habits. Innuendo and slur are common: The players drank too much or did drugs, their IQs were low to begin with, they came from difficult backgrounds, and all of that is why they now have emotional and cognitive problems. Not their battered brains.

Of course, no one mentions that almost identical arguments were first made in the 1930s and 1940s about boxing.

Similarly, sport concussion authorities today reject the association of hits to the head with the production of disease and refuse to adopt precautionary measures ensuring informed consent. Meanwhile, the Illinois report and the context of its creation tell a very different story. Indeed, the report’s existence suggests that from the 1940s until the mid-2000s, sports authorities ignored and even unlearned what clinicians already knew about CTE. Rather than accepting that knowledge, stigma, and a distaste for losers helped conceal the truth – and what it clearly implied for all collision sports.

Disclosure: Stephen T. Casper is retained by plaintiffs in concussion litigation pending in the United States and the United Kingdom.