History of Chronic Traumatic Encephalopathy

Robert C. Cantu, MA, MD, FACS, FACSM, FAANS; Charles Bernick, MD, MPH

Disclosures

Semin Neurol. 2020;40(4):353-358. 

In This Article

Abstract and Introduction

Abstract

The long-term effects of repetitive head impacts have been recognized for close to a century. What is now referred to as chronic traumatic encephalopathy (CTE) was first described by Martland in 1928 in a series of boxers. Over the years, several important articles were published, including Critchley's 1957 report where he introduced the term "chronic traumatic encephalopathy," Robert's study in 1969 which provided evidence of the prevalence of neurological impairment in retired fighters, and Corsellis' initial description of the pathology of CTE. However, what brought public attention to the issue of CTE in sports were the postmortem findings of CTE pathology in professional American football players, initially reported by Omalu and subsequently in a large series by McKee. There is now standardization of pathological criteria for CTE and recognition that it can be seen across all activities that involve repetitive head impacts.

Introduction

Most would say that the classic, and often cited, article by Dr. Harrison Martland on the punch drunk syndrome in a 1928 issue of the Journal of the American Medical Association (Figure 1) was the first description of the clinical syndrome of chronic traumatic encephalopathy (CTE).[1] Dr. Martland was a New Jersey coroner who reported the clinical pattern of cognitive, behavioral, and mood issues he observed in a series of boxers. In that 1928 article, he coined the term "punch drunk" and described it as follows:

Figure 1.

Harrison Martland, MD, pictured on the right, was the first to describe punch drunk. His article appeared in the Journal of the American Medical Association in 1928.1

For some time fight fans and promoters have recognized a peculiar condition occurring among prize fighters which, in ring parlance, they speak of as "punch drunk." Fighters in whom the early symptoms are well recognized are said by the fans to be "cuckoo," "goofy," "cutting paper dolls," or "slug nutty."

The early symptoms of punch drunk usually appear in the extremities. There may be only an occasional and very slight flopping of one foot or leg in walking, noticeable only at intervals; or a slight unsteadiness of gait or uncertainty in equilibrium. These may not seriously interfere with fighting. In fact, many who have only these early symptoms fight extremely well, and the slight staggering may be noticed only as they walk to their corners.

In some cases periods of slight mental confusion may occur as well as distinct slowing of muscular action. The early symptoms of punch drunk are well known to fight fans, and the gallery gods often shout "Cuckoo" at a fighter. I know of one fight that was stopped by the referee because he thought one of the fighters intoxicated.

Many cases remain mild in nature and do not progress beyond this point. In others a very distinct dragging of the leg may develop, and with this there is a general slowing down in muscular movements, a peculiar mental attitude characterized by hesitancy in speech, tremors of the hands, and nodding movements of the head, necessitating withdrawal from the ring.

Later on, in severe cases, there may develop a peculiar tilting of the head, a marked dragging of one or both legs, a staggering, propulsive gait with the facial characteristics of the Parkinsonian syndrome, or a backward swaying of the body, tremors, vertigo and deafness. Finally, marked mental deterioration may set in necessitating commitment to an asylum.

Martland believed that symptoms appeared in up to half of all veteran boxers. Because of his personal observations at the ringside, he had the insight to realize that boxers who had the greatest number of fights, who had a long duration of fighting, who were sluggers (taking a lot of blows), or who sparred extensively were most likely to show this clinical triad of mental confusion and recent memory impairment, emotional lability with mood swings and diminished ability to control temper, and parkinsonian signs including tremor, rigidity, and bradykinesia. In addition to this triad, he also mentioned seeing in later stages slurred speech and loss of balance due to cerebellar injury. Martland, thus, recognized the importance of dose of repetitive head impacts (RHI) as a major risk factor for developing CTE.

As an interesting side note in Martland's article, there are a several paragraphs about Gene Tunney, who held the heavyweight boxing title from 1926 to 1928.

In discussing his retirement from the prize ring, Gene Tunney said in connection with his training for the second Dempsey fight: "I went into a clinch with my head down, something I never do. I plunged forward, and my partner's head came up and butted me over the left eye, cutting and dazing me badly. Then he stepped back and swung his right against my jaw with every bit of his power. It landed flush and stiffened me where I stood. That is the last thing I remembered for two days. They tell me that I finished out the round, knocking the man out." Tunney further stated that it was forty-eight hours before he knew who he was, and not until the seventh round of the Dempsey fight was he entirely normal. In concluding, he said: "From that incident was born my desire to quit the ring forever the first opportunity that presented itself. But most of all, I wanted to leave the game that had threatened my sanity before I met with an accident in a real flight with six ounce gloves that would permanently hurt my brain."

He did win, and he retired from boxing and went on to have a very successful business career and long life, dying at the age of 81 years.

Over the next half century, multiple retrospective studies (described later) of predominantly professional boxers appeared that supported Martland's views.

Terminology

The term "chronic traumatic encephalopathy" actually did not enter the medical lexicon for at least a decade after Martland's article. Several alternative terms were used, including traumatic encephalitis,[2] traumatic encephalopathy,[3] traumatic encephalopathy,[4] dementia pugilistica,[5] and psychopathic deterioration of the pugilist.[6]

Arguably the term "chronic traumatic encephalopathy" was coined by Bowman and Blau when they described the case of a 28-year-old professional boxer in their book chapter "Psychotic States following Head and Brain Injury in Adults and Children."[7] Upon his presentation to the psychiatric division of Bellevue Hospital, the boxer's wife reported that for the two previous years the patient had exhibited increasingly childish behavior and was occasionally depressed. Though the patient wanted to return to professional boxing, the boxing commissioner refused him on account of his poor mental health. The patient was described as having paranoia, including feelings of being poisoned, stalked, and deceived. He also was involved in violent assaults and had been arrested for shouting at strangers. He lacked insight into his condition, had poor orientation, could not grasp simple concepts, and had poor short-term memory. It is also notable that the patient abstained from alcohol and that he experienced many knockouts during his boxing career. The authors initially diagnosed this young boxer with traumatic encephalopathy; however, after seeing that his condition remained unimproved over 18 months, they changed their diagnosis to reflect this, and the term "chronic traumatic encephalopathy" was born.

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