The Concussion Crisis

by Linda Carroll

  Three years later, the secret became public during a deposition Patterson gave for a civil suit brought by a promoter challenging the commission’s ban on “ultimate fighting.” Although he still appeared to be in fighting trim at sixty-three, there was a confused look behind his pleading hangdog eyes. Under questioning from a lawyer, Patterson couldn’t remember the name of the heavyweight champion he dethroned to first win the world title. He couldn’t remember the site or the year of that career-making title fight. He couldn’t remember the names of his other opponents. He couldn’t remember the names of his closest aides, his secretary, the commission’s lawyer. He couldn’t remember the name of his predecessor as chairman of the commission. He couldn’t remember the names of his two fellow commissioners. “One’s a lady and one’s a man,” he said finally.

  This went on for three hours with no referee to step in and stop it. He seemed as dazed and bewildered as a boxer stumbling around the ring. He was confused about the most basic rules of boxing, unable to recall the size of the ring or the number of ringside judges; he didn’t remember that the length of title fights had been cut to twelve rounds over a decade earlier in the wake of a nationally televised ring death. At one point, he said, “What are we talking about? I’m lost. Who’s the plaintiff?” Over and over, he tried attributing his memory lapses to lack of sleep. “It’s hard for me to think when I’m tired,” he explained. “Sometimes, I can’t even remember my wife’s name, and I’ve been married thirty-two, thirty-three years. Sometimes, I can’t even remember my own name.”

  Floyd Patterson, as gallant and gracious an ambassador as the savage sport had ever known, immediately resigned his position. When he died eight years later, Patterson was remembered for his familiar storybook rise, from the mean slums of Bedford-Stuyvesant to the heavyweight championship of the world, and for his all-too-familiar descent into the depths of Alzheimer’s dementia—the latest in a long line of ring legends to succumb to the occupational hazard of their chosen profession.

  Chapter 10

  Ticking Time Bombs

  On a cool fall Saturday in 2002, Dr. Bennet Omalu sat with his first cup of coffee in his Pittsburgh apartment, flipping through the channels catching bits and pieces of the morning news. One story grabbed his attention and made him set down the remote: Football Hall of Famer Mike Webster had died at the age of fifty after years of bizarre behavior and homelessness. What intrigued Omalu was not the replays of Webster’s career highlights, but rather the description of the man’s decade-long descent into mental illness after retiring from the NFL.

  With bulging biceps and steely tenacity that won over every lunch-pail football fan in Pittsburgh, Iron Mike Webster had spent seventeen savage seasons forging a reputation as the best center in NFL history and powering a Steelers dynasty to four Super Bowl titles. Toward the end of his career, the warrior hailed for his iron will as much as his physical toughness started to come apart. By the time Webster retired at thirty-eight, his behavior had already become so odd that his wife and four kids were scared. He’d fly into rages, smashing his cherished football memorabilia, once even demolishing a porcelain sink. More disturbing were episodes like the time he got up from the dinner table, walked over to the stove, opened the oven, urinated into it, and then casually returned to the table as if he’d just used the bathroom. Webster was unable to hold down a job and squandered the family’s savings through bad business investments. When the same ex-teammates who’d once voted him Steelers captain offered to help, he pushed them away. Soon he was wandering the streets homeless, sleeping some nights slumped in his dilapidated pickup truck in deserted parking lots, other nights huddled in the downtown Pittsburgh train station near the stadium where he’d once basked in the cheers of sixty thousand Steelers fans. He spent his final years drifting in and out of lucidity, overwhelmed by dread, depression, and paranoia.

  As Omalu drove to work that gray Saturday morning, still mulling over the story he’d just seen on TV, he wondered how this could have happened to such a tough, hulking, seemingly indestructible athlete. The radio droned on with talk show hosts and callers slamming Webster—once a beloved Steel City icon—as yet another sports hero who couldn’t make the transition from ballfield to real life. All the talk made Omalu angry. He was sure something must have happened to Webster’s brain that would explain his behavior. Omalu thought about how violent football was and how he avoided watching it for that very reason. He wondered whether the hits that linemen like Webster sustained on every play might somehow be comparable to the blows absorbed by boxers: Was it possible that football players were susceptible to something like dementia pugilistica? Omalu shook his head and thought, “It doesn’t matter anyway. I’m just an insignificant doctor with no clout. What can I do?” He parked his car and, as he opened the door to his building, resolved not to spend any more time dwelling on something he could do nothing about.

  Omalu walked into the coroner’s office, wondering what he would find today on his autopsy table, and instantly recognized the embalmed body from what he’d just been watching on TV. It was Mike Webster.

  Omalu stepped out of the autopsy suite to ask why Webster was there, since initial news reports had attributed the death to a heart attack. He was told that Webster’s physician had written “chronic concussive brain injury” on the death certificate, implying that an element of trauma had contributed to the player’s demise. Because that meant the death might not be due to natural causes, it fell to the coroner’s office to perform an autopsy. As the forensic pathologist on duty, Omalu was responsible for determining cause of death. He cracked open Webster’s chest, removed the heart, and examined it. He quickly determined that Webster had indeed died as a result of a heart attack.

  Omalu, however, wasn’t ready to finish the autopsy. The neuropathologist in him was sure that if he examined the brain, he could find answers to his questions about Webster’s descent into depression and dementia. He carefully cut an incision from ear to ear over the crown of Webster’s head and then peeled the scalp away from the skull. After sawing through the bone, he removed a cap-shaped piece of skull, revealing the pink, corrugated lump of tissue that was Webster’s brain. He carefully slid his gloved hands under the brain and gently lifted it from the skull. He stared at it from every angle, looking for imperfections among all the ridges and crevices, but there were none. It looked perfectly normal. He ran his fingers over the bumpy surface, feeling for soft spots, but there were none. He was disappointed. With the degree of mental deterioration that Webster had exhibited in the twelve years since his retirement, Omalu had expected to find visible signs of brain damage.

  Instinctively, he started to do what he normally would when finishing up an autopsy. He scooped up the brain and started to put it back into Webster’s skull to prepare the body for burial. But then suddenly, Omalu heard a voice in his head whispering, “Bennet, save this brain.” Omalu paused and wondered if this was Mike Webster’s soul trying to speak to him, telling him to keep searching for the answer. Omalu knew that people could have significant symptoms with only microscopic brain damage. If he had a chance to cut up the brain and make slides to examine under his microscope, he might find some clues. As a rookie pathologist with just two months on the job, he would need permission from the coroner as well as from Webster’s family to perform a more extensive examination of the brain. In the meantime, he tucked it in a jar of preservative solution. Then he called Webster’s lawyer to get permission from the family to examine it in more detail. He explained to the lawyer that this was a chance for Mike Webster to tell the world in death what he was unable to say in life. It didn’t take long for Omalu to get his answer—and the brain.

  Omalu went to work thin-slicing the brain. He sent some of the slices off to the University of Pittsburgh for mounting on slides and staining with dyes that would highlight the two telltale proteins suffusing the brains of Alzheimer’s patients and of boxers suffering from dementia pugilistica. Sure enough, when the slid
es came back and he put them under his microscope, he saw clear proof of brain damage. On the slides stained to highlight tau, he saw dark brown bloated neurons, indicating cells stuffed with tangles of twisted protein threads. On the slides stained to highlight amyloid beta, he saw irregular smudges of reddish brown in between neurons, indicating clumps of the sticky protein.

  Omalu wasn’t sure what it all meant, so he took his slides over to the University of Pittsburgh to consult with one of the nation’s leading Alzheimer’s experts. Dr. Steven DeKosky pored over the slides and said, “Bennet, this is not Alzheimer’s.” DeKosky explained that Alzheimer’s disease always starts in the hippocampus and then, over the years, wreaks havoc on that deep brain region. Omalu’s slides showed no traces of damage to the hippocampus. Omalu suggested that perhaps what they were seeing was the same disease that led to dementia in boxers. Since much of the damage appeared in Webster’s cortex, that made sense to DeKosky. He and Omalu both recognized the significance of the finding: the first autopsy-confirmed case of a football player found to have the same dementing brain disease previously thought to strike only punch-drunk boxers who’d taken countless blows to the head.

  Omalu, who regarded pathologists like himself as advocates defending and speaking for the dead, raced off to tell Mike Webster’s children and ex-wife what the brain had told him. Now he could assure them that all of the odd and inexplicable symptoms—the memory loss, the emotional swings, the behavioral problems—were not Mike’s fault but rather the fault of twenty thousand hits to his helmet. It explained how the loving, caring, funny father they once knew came to be begging them to zap him into unconsciousness with a Taser gun in a desperate attempt to escape his back pain and get some sleep. It explained how he came to be squeezing Super Glue onto his gums in a confused attempt to reattach rotted teeth to his jaw. The forensic findings finally gave the family some peace and some closure—as well as some more ammunition in their ongoing battle with the NFL.

  Webster had spent the last three years of his life fighting the league and its players’ union for disability benefits based on his traumatic brain injury. After his claim was filed in 1999, the NFL’s pension plan awarded him only partial benefits, a fraction of what he would have received for a full disability related directly to playing football. His lawyer promptly filed an appeal that included medical reports from a psychiatrist, a psychologist, and a neurologist who was handpicked by the NFL. The doctors all agreed on the diagnosis: a dementing disorder that resulted from multiple head injuries sustained playing football and that had left him disabled since his retirement in 1990. Following his death, the NFL pension board denied the appeal for retroactive benefits, holding that his disability did not show up until long after his retirement.

  Now, with Omalu’s autopsy, a neuropathologist had provided hard scientific evidence of the same diagnosis that the psychiatrist had made three years earlier based on symptoms: chronic traumatic encephalopathy caused by repeated head trauma sustained while playing on the offensive line. The courts would find all the medical evidence overwhelming. A federal judge ruled in favor of Webster’s claim in 2005, and when the NFL challenged that, a federal appeals court unanimously upheld the ruling and awarded more than $1.5 million to the estate in retroactive benefits. Everyone seemed to agree that Iron Mike Webster had been completely and permanently disabled as a result of brain injuries from playing pro football. Everyone, that is, except the NFL.

  Omalu would discover just how deep the league was digging in its cleats when he submitted his groundbreaking case study to Neurosurgery, the same medical journal that was in the midst of publishing a series of papers written by the NFL’s Mild Traumatic Brain Injury Committee. The publication of Omalu’s article in the July 2005 issue of Neurosurgery rocked the football establishment, coming as it did just six months after the journal had printed a study by the NFL committee concluding that multiple concussions were benign, transient events with no long-term consequences. Dr. Elliot Pellman, the NFL committee’s chairman and the lead author on its controversial study, joined with his co-author Ira Casson, an expert on dementia pugilistica, in trashing Omalu’s article in a long letter to the editor. They attacked everything about Omalu’s paper, starting with the title—“Chronic Traumatic Encephalopathy in a National Football League Player”—because they claimed there was no evidence that Webster’s condition was chronic or traumatically induced or, for that matter, even encephalopathy. They claimed the article had “serious flaws,” specifically a “serious misinterpretation” of its own neuropathological findings, a “complete misunderstanding” of the condition that afflicts boxers, and a failure to show causation through an adequate clinical case history. They demanded that Omalu and DeKosky “retract their paper or sufficiently revise it and its title after more detailed investigation of this case.”

  Not only did Omalu refuse to retract or revise it, but by now he had another case study to back it up.

  As luck would have it, Omalu had shown up for work one spring day in 2005 to find the body of another former Steelers lineman on his autopsy table. Terry Long had played eight seasons for the Steelers, the first five right alongside Webster on the offensive line. After Long retired in 1991, having already attempted suicide once with sleeping pills and rat poison, he plunged into a mental decline that paralleled Webster’s. Long became volatile, irrational, impulsive, and paranoid. A tempest of bad business decisions left him deep in debt and under indictment for felony fraud. Clinical depression led to more suicide attempts and three hospitalizations for psychiatric treatment. He was just forty-five when he died after drinking antifreeze. Because suicide was suspected as the cause of death, his body wound up on Omalu’s table at the Allegheny County coroner’s office in Pittsburgh.

  Omalu, struck by the parallel to the Webster case, jumped at the fortuitous opportunity to examine the brain of another former NFL player. To the pathologist’s naked eye, Long’s brain looked as normal as Webster’s had. As with Webster’s, Omalu stored Long’s brain in preservative solution for slicing, staining, and examination. As with Webster’s, Omalu peered through his microscope at Long’s slides and saw clear evidence of brain damage. The dark brown blotches riddling Long’s brain reminded Omalu of the bloated neurons that he’d seen on Webster’s slides. Their appearance signaled the presence of tau tangles, the true telltale sign of chronic traumatic encephalopathy. With Long’s slides showing none of the amyloid beta plaques found in Webster’s, the tau was all Omalu needed to confirm the second case of a middle-aged football player whose brain resembled that of a demented old man twice his age.

  Omalu’s boss, Cyril Wecht, the controversial coroner notorious for offering expert commentary on high-profile deaths, immediately saw another chance to jump into the fray. To the lengthy list of cases he’d made news consulting on and commenting on over the years—John F. Kennedy, Elvis Presley, Sunny von Bülow, JonBenét Ramsey—Wecht added the name Terry Long. Wecht, the forensic pathologist who’d been a lightning rod since he challenged the single-bullet theory in JFK’s assassination, released his office’s autopsy report attributing Long’s death to inflammation of the brain lining from repeated head injuries on the gridiron. “This is analogous to what is colloquially known as being punch-drunk,” Wecht declared. “We believe the microscopic changes in the brain are consistent with chronic traumatic encephalopathy or a degeneration over time that set the stage for the final result. You don’t have to be a doctor or an engineer or even a football player to realize that the helmet does not block out all the measured force produced when some three-hundred-pound player with a hand the size of a Christmas ham whacks you in the head dozens of times a game, season after season.”

  The team neurosurgeon for the Steelers, Dr. Joseph Maroon, responded quickly by attacking Wecht’s statements and Omalu’s findings. “I think the conclusions drawn here are preposterous and a misinterpretation of facts,” Maroon told reporters. “I think it’s fallacious reasoning, and I don’t think it’s
plausible at all. Given Mister Long’s history of drug abuse and suicide attempts or whatever altercations may have contributed to his demise, I think it’s just bad science to conclude that football caused his death. To go back and say that he was depressed from playing in the NFL and that led to his death fourteen years later I think is purely speculative. I think it’s not appropriate science when you have a history of no significant head injuries. I was the team neurosurgeon during his entire tenure with the Steelers. I rechecked my records. There was not one cerebral concussion documented in him during those entire seven years. Not one.”

  The fact was, Long had indeed once sustained a documented concussion severe enough that Maroon recommended he sit out at least one week. How many more went unreported was anyone’s guess. That was even truer with Iron Mike Webster, a warrior revered for playing through all manner of pain for 177 consecutive games. Since neither Webster nor Long had a significant history of diagnosed concussions, alarms should have sounded as soon as chronic traumatic encephalopathy was found on autopsy. Playing on the line of scrimmage, where the collisions aren’t nearly as spectacular as the full-speed crashes in the open field, Webster and Long absorbed hits to the helmet from defensive linemen launching at them every time the ball was snapped. Omalu’s autopsy findings raised questions about the cumulative effect of these countless blows—the same formula implicated in the boxing epidemic known as dementia pugilistica.

  Although Long’s death certificate would later be amended after toxicology tests linked his fatal brain swelling directly to the antifreeze he drank, Omalu maintained that the football-induced chronic traumatic encephalopathy was a contributing factor by causing the depression that led to the suicide. By the time Omalu’s second case study was published in the November 2006 issue of Neurosurgery, the acronym CTE had entered the football lexicon and a new variant of dementia pugilistica had crept from the ring to the gridiron.