On September 29, 2015 the New York Times published an article by Dave Phillips with the headline “Concussions in a Required Class: Boxing at Military Academies.”
For more than a century, boxing for male freshman here has been a rite of passage and an academic requirement – one they share with male cadets at the Air Force Academy and midshipmen of both sexes at the Naval Academy. Officials say there is no better way to teach the grit needed for combat.
According to Lt. Col.Nicholas Gist, the director of physical education at West Point, “We want to expose them to fear and stress and teach them a confidence to respond…we’d rather teach that at the academy than in Iraq or Afghanistan.
According to the Times, “In the last three academic years, West Point has documented 97 concussions from boxing, more than from any other sport, although more cadets box because it is mandatory. The Air Force Academy has reported 72, and the Naval Academy 29.” And West Point officials add, no doubt with their brass cojones, “Cadets too concussed to complete the boxing class are required to repeat it.” It seems Col Gist and the other numbskulls (if there is a pun there, it is intended) at West Point think it is okay to get a second brain injury; that will prove you have twice as much “grit for combat.”
Those who have read previous posts to this blog have repeatedly heard the heartfelt mantra of this writer: “There is no such thing as a minor brain injury.” Trauma to the head is transferred to the brain, and even when the person who is hit is not aware of symptoms, there is overwhelming evidence that there is still injury to the brain which can and does accumulate over time and may well result in degenerative changes and dementia. So, it is very likely we can increase the numbers of cadets who suffer brain injuries to double the number reported by the tradition bound and ignorant military authorities. The Times points out the history of this academic requirement is 110 years old.
Boxing was made a requirement at West Point in 1905 at the behest of President Theodore Roosevelt, joining horsemanship and swordsmanship as necessary skills for young officers. And though swords and horses were cut long ago, boxing remains. It has endured even as the military, after 10 years of battling roadside bombs in Iraq and Afghanistan, has become increasingly aware of the seriousness of traumatic brain injury, spending hundreds of millions of dollars on research and treatment.
I would quibble with the Times summary only in that we have been in Iraq and Afghanistan, exposing our troops to repeated traumatic brain injuries, for longer than 10 years now. And the money spent on research and treatment are wasted when the DOD still does not recognize the nature and severity of the problem and not turn major efforts to Prevention. The public relations cover of the DOD aside, it is clear they still don’t get it. Just like enabling substance abuse, command is enabling traumatic brain injuries. Surely requiring boxing as an academic requirement at the academies is the most accurate assessment of how seriously command thinks about trauma to the brain. No wonder the leadership in the military has been in decline the last 70 years. The officer corps has been beating their brains out at the military academies. How many cadets and midshipmen (and women) will have Dementia Pugilistica (or its modern equivalent chronic traumatic encephalopathy CTE) in the future.
I had never heard the term “Dementia Pugilistica” until 1975. As part of my Neurosurgical Residency I was required to spend 6 months exclusively on the Neurology Service of the University Medical Center. The Chairman of the Neurology Department was a man by the name of Dr. Robert Currier. I suspect there is never a day to go by that I do not recall and use some gem of knowledge that this great physician and teacher taught me. Some of the most memorable times of my neuroscience education were in the evenings when the pressures of the day were lessening and Dr. Currier would say to me, Let’s go talk to some patients.
On one of those late winter evenings, we were introduced to a man of 45 years who had been brought to the hospital by his family because he could not longer walk, talk or eat. He had been a professional boxer from his late teens until his late 30s, and he had over 150 official boxing matches. At one time he was a middleweight contender, but he never achieved the crown. In the later years of his career he was knocked out a number of times, according to his family. You might remember his name, but I still want to protect his identity. To give you some idea of his deficits, he looked like a smaller version of Muhammed Ali. Very slow movements, with tremor, slurred speech and severely impaired cognition. He looked at least 30 years older than his stated age. After we talked Dr. Currier gave me an assignment to research Dementia Pugilistica and give a talk to the other residents. At the same time he told me he was going to talk with the family about getting the brain of this patient after he died.
Though Dementia Pugilistica has been part of the human condition for centuries, or as long as man has chosen to bash the brains of their foe. But the syndrome was first described by a forensic pathologist in 1928 (Martland HS, Punch Drunk. Journal of the American Medical Association. 91 (150: 1103-1107), and in 1973 the pathological changes were described in 15 former boxers (Corsellis, et al. The aftermath of boxing. Psychological Medicine. 3(3): 270-303. There is now an impressive list of studies documenting the pathology of repeated trauma to the brain that occurs in boxing. The syndrome is now being called chronic traumatic encephalopathy, that syndrome being seen in football players in the years after they stop playing. It begins with the repeated injuries they sustain when they are adolescents, playing in high school in particular, when the brain is particularly vulnerable. It is true, in general football players are not trying to inflict a loss of consciousness on their opponents, as they are in boxing; but the long term effects of repeated brain injuries, concussion level or not, are predictable and inexorable.
Back in 1975 Dr. Currier did get permission from the family of our boxer to remove, preserve and examine his brain at the time of autopsy. I was privileged to be present on the day we examined this patient’s brain. Every two weeks, on Saturdays usually, we had a teaching session called “brain cutting.” Members of the faculty and residency programs would gather in the morgue and there would be 6 to 8 brains displayed of the autopsy table; they had been preserved and “fixed” 6 to 8 weeks previously, ready for examination and sectioning. These sessions were profoundly informative, serious and sober exercises. I learned so much about trauma to the brain from being allowed to examine the brains of these patients. Our boxer’s brain was so fragmented it weighed ¼ of what you would expect in a man his age and it had the appearance of distressed swiss cheese. The picture accompanying this text is not the brain of our boxer, but does represent a portion of the brain of a football player with chronic traumatic encapholopathy, which could the typical picture of a boxer with Dementia Pugilistica.
At West Pont the superintendent, Lt. Gen. Robert Caslen Jr. told the Times boxing is the best way to “instill courage” and “he was unwilling to sacrifice teaching cadets how to overcome the fear of facing an opponent.” Of course he did not give any peer reviewed scientific studies supporting this statement. It seems General Caslen played football at West Point and looked back with pride and nostalgia on his concussions as a cadet: “I’ve been knocked out, given smelling salts and shoved back in there—that was our concussion protocol back then…I always thought it was a badge of honor when I got a concussion—now you are one of the guys. You get knocked out and keep going.”
I have only one thing to say to Gen Caslen: “Can I have your brain to examine after you die from your dementia?”
Don’t hold your breath waiting for the military culture to change. After all, it is just about the brain. On the other hand, there is growing public awareness of the hazards of traumatic brain injury in youth contact sports. Unfortunately, as reported in the latest edition of Neurology Times, October 9 (UBM Medica, LLC)
The data regarding return to play shows that the current pattern is far from ideal for most patients, with a study out of Boston reporting that over half of treating clinicians experienced pressure from coaches or players to return athletes prematurely to play. Another peer reviewed article reported that almost 45% of concussion patients returned to school or sports too soon.
As the article stresses, “there is no effective medical means to repair or speed up brain tissue recovery after a concussion.” So, the current initiative is to provide grading scales to quantify the severity of neurologic function after TBI. However, what about those situations where there is obvious external trauma and the player has no neurological signs or symptoms. We all have seen it at all levels of competition; for instance the high school linebacker puts a vicious hit on a running back, with an inadvertent helmet to helmet collision. Despite the impact both players get up and strut about without apparent injury. All is well it seems, but we have no idea about the energy transferred to the brain, but it is likely there has been some diffuse axonal injury. It may not be overtly expressed in neurological signs and symptoms until the next hit, or for years to come. So no check list or guideline is going to help. The key is preventing repeated blows to the head in the first place.
References from Neurology Times:
Carson JD, et al. “Premature return to play and return to learn after a sport-related concussion: physician’s chart review.” Can Fam Phys. 2014 Jun; 60(6):e310-e315.
Kroshus E, et al. “Pressure on Sports Medicine Clinicians to Prematurely Return Collegiate Athletes to Play After Concussion.” J Athl Train. 2015 Sept, 50(9):944-951.
McKean JM, et al. “Trends in concussion return-to-play timelines among high school athletes from 2007 through 2009.” J Athl Train. 2013 Nov-Dec; 48(6): 8360843.