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Credit: Flickr user Monica’s Dad
In an ancient Aztec cultural practice, priests would choose a man to represent one of their gods, Tezcatlipoca. The man would be worshiped as a god for a year, but at a preordained date, the priests would sacrifice him, sometimes cannibalizing his body. Each year the priests turned from the sacrifice to select a new “god,” repeating the cycle of reverence and destruction.
I wonder what the Aztecs would make of the view in front of me. I am in a sports bar with my family, eating after a walk around town. The other patrons’ eyes mostly rest, enthralled, on the many football games televised before them. One can’t avoid watching the flatscreens that hang off every wall, or the brutal athleticism they capture. Throughout each play, the players’ heads can be seen as shells traveling at a certain vector, pinballing with others, sometimes whipping to sudden impacts with the ground. Force equals mass times acceleration. Masses hit each other with high velocities, creating sudden and twisting accelerations, and the forces proportionally rise. No human rule trumps physics.
The high-definition flatscreen TVs show it all, but don’t provide a deeper, more physiological look. Inside a football helmet is a skull, and inside each skull is a free-floating brain. Inside the brain are billions of neurons, chattering with each other in a code we scarcely understand, wired to each other with long and slender projections called axons. An internal scaffolding structure holds each axon in place. The axons crisscross the brain, side to side, forwards and backwards, up and down.
As force is applied to the brain, a shockwave ripples through. If large enough, the shock tears the axons and can result in catastrophic injury. Smaller forces stun the neurons, their electrical firing decreases, and symptoms of concussion occur. The player may go limp, or stumble and appear unfocused. He is usually amnestic of the event. If the force is milder, none of these symptoms may manifest, but the changes are still felt in the long and slender axons. Their supporting scaffolds, on a human scale akin to bridges from San Francisco to Taipei and Perth to Cape Town, experience an earthquake.
Over and over, every head blow stresses the scaffolding. A protein called tau normally stabilizes the scaffolds, but the tau proteins become dysfunctional, pathologic, then malignant. The tau binds together, twists in on itself, assembles into sharp aggregates that poke holes in the fragile cell wall and kill the neuron. A neuron goes silent, its axonal bridge crumbles. As the brain digests the dead neuron, it leaves behind the twisted skeleton of the tau aggregate, a “tangle.”
Other than the injuries that are so obvious they leave the player unconscious, impaired, or dead, we do not know exactly how harmful low-velocity impacts are. We see the ice above the water—in the form of a stunned and staggering player—but we’re starting to realize how deep the risk extends. Emerging data shows low-force head blows produce tau pathologies. Over time the minor head injuries combine and the tau can turn malignant. When enough cells die, symptoms begin. It is now known as chronic traumatic encephalopathy (CTE). It was “dementia pugilistica” when I was in med school, falsely implying a restriction to boxers, as in the later Rocky movies. Before that it was called “punch drunk.” Just as “shell-shock” came before “Post-Traumatic Stress Disorder,” these are different names for the same problem. It leaves victims with cognitive and emotional derangements, prone to odd behaviors, suicide, and dementia. There is no treatment. In the parlance of the announcers, you can’t unring the bell.
Knowing all this, I can hardly watch the game, but I can’t stop myself from watching either. The plays on the bar’s screens are a thrilling combination of grace, toughness, and skill, and the sport is easily seen as a metaphor for all that is great in humans. But within this escapism it’s easy to forget that football is only a game, albeit one with real-world sacrifices and consequences.
Consider the case of Owen Thomas, a University of Pennsylvania football player who committed suicide, and whose parents afterward came forward to expose the truth behind the tragedy. Thomas’s brain carried an amount of skeleton tangles that would be expected in mild dementia. His impact burden was small, and he may never have even suffered a concussion, yet at only 21 years of age, his brain showed tangles, which have become the signature injury from repetitive head traumas. Tangles are a signature for which football carries a pen full of ink.
From junior-high football and even earlier, boys are told to hit hard. Even though they may never suffer a concussion, they do suffer head blow after head blow. It seems no one is safe, and the level of risk is unknown. Mr. Thomas did not have unique neuropathology; there are other deceased players who have displayed similar symptoms: Chris Henry, John Glenn Grimsley, and Justin Strzelczyk, to name just a few. There are likely to be many more still unrecognized, and, judging from the bizarre behavior of others still living, more to come. As of now, the youngest case was an 18-year-old player. It seems the more football players’ brains come under neuropathologists’ microscopes, the more pathology they display.
Perhaps it is wrong to directly compare football to a dead religion that sacrificed young men and ate them. But it is easy to do partially because the Aztecs were honest: one year as an enslaved god, then death. We don’t have the data, so we can’t offer a timeline, or a reasonable cap on concussions, or guess at the probabilities of a player losing his mind in the next year, three years, or three decades.
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