PHYSICAL SIDE OF FOOTBALL

The current number of the Boston Medical and Surgical Journal contains a paper on "The Physical Aspect of American Football" written by Dr. Edward H. Nichols '86 and Dr. Homer B. Smith '00, the two surgeons who had charge of the Harvard football squad this fall. That article is here reprinted, by courtesy of the Harvard Bulletin, except for a certain portion which is a technical description of the injuries received in the game and the methods and appliances used in treating them; and a list of injuries received while playing football prior to 1905, and a list of injuries received during 1905.

The report is presented, first, in order to show the number, character and severity of the injuries which were received, while playing football, by the members of the football squad of one university. The first table of figures includes all injuries received by the players previous to this season, while playing football either at school or at college; the second table includes all injuries received this year. Second, to illustrate general methods which were found to be useful in the treatment of acute traumatisms common among football players; and, finally, to present certain special methods of treatment of special injuries.

The report is based upon (1) the written statements of the players themselves regarding the injuries they had received while playing football previous to this year. Every man was required, on joining the squad, to make out a card for a card catalogue, on which he stated the number and character of his previous injuries. (2) Clinical records which were kept by the writers of the cases which came under their observation and treatment. These records were kept only in cases of injuries of great or moderate severity, practically all of which were sufficient to keep men out of the play for a greater or less length of time. No clinical record was kept, however, of the infinity of minor injuries which constantly came under observation, such as abrasions, scratches, minor contusions. (3) The answers received to a circular letter which was sent, after the close of the season, to every one who had been at any time a member of the squad. This circular letter asked the number and character of previous injuries, the length of time they were kept out of the play by those injuries and the length of time they were kept away from college duties, and whether recovery from those injuries was now complete. Similar questions also were asked in regard to injuries received during the season of 1905. A hundred and fifty such circular letters were sent out and answers were received from one hundred and ten men.

Besides the members of the university squad, players from the freshmen and class squads also were treated, but no clinical record was kept of those cases, nor are they included in the statistics presented in this paper, although a considerable number of serious injuries was treated among members of those squads.

There were 150 men altogether in the football squad, of whom 50, at least, played but a very short time, varying from a few days to a week or two. Of the remaining 100, only 70 can be said to represent the real playing strength of the football squad. This fact makes the proportion of injuries received this year almost double as great as would appear at first sight.

It has been claimed that the number of injuries received this year was unusually great and more numerous than in any preceding season. In the absence of any available records of other seasons, this point cannot be determined accurately, but in our opinion it is probable that this season is not markedly worse than preceding ones. We are confirmed in this opinion by interviews with other men who previously have had medical charge of the football squad. One or the other of us was constantly present at the field, from half past three or earlier until dark. The men were very carefully observed and many injuries were recognized which would have escaped less close observation. In comparing the figures in this paper with those of other institutions where no constant surgical attendance is maintained, the numbers may appear relatively large because, in the absence of such observation, many injuries would escape notice.

The players of the university squad were required by the head coach to report every injury no matter how trivial it seemed to them, to the surgeon in charge. In expectation of numerous minor injuries and with a knowledge of the occurrence, in some previous years, of occasional epidemics of minor infections, special precautions were taken regarding asepsis this year. In the first place, an efficient sterilizing outfit was installed. A sufficient supply of clean towels was provided in order to prevent the possibility of transmission of skin infections, and pains were taken to see that the underclothing of the players was changed frequently. As a result of these precautions there was no case of an infected wound during the season nor did any case of skin infection occur. This result, we believe, has not been paralleled in former years.

Believing that a first-class man slightly injured was inferior to a second-rate man in first-class physical condition, great pains were exercised to prevent injured men from returning to the play too soon. This apparently excessive caution of the surgeons met in some cases with bitter opposition from the players. In fact, one man, at least, stated that if it were not for the presence of a surgeon, he would be playing. The wisdom of caution, however, was shown by the fact that in but two cases were men allowed to play so soon as to have an immediate recurrence of their previous disability. On the other hand, it must be stated that the position of the surgeon is rather a trying one. Football players are quite unlike ordinary private patients. Their disregard for pain is marked and their great desire is to be sufficiently recovered from injury to be able to play, and in spite of what was considered by the players to be excessive caution, a certain number of

"chances" were taken. For instance, a patient, under ordinary circumstances, with a dislocated semilunar cartilage, would be perfectly contented to lead a more or less quiet life for a considerable length of time. The football player, however, as soon as the acute symptoms have disappeared, is quite unwilling to be prevented from playing. In no case was any sedative drug used in order to deaden the pain of an injury so as to allow a player to take part in a game before recovery was complete.

The injuries were received in various ways: some in open play, some in the mechanical drill of "tackling the dummy," but a very great proportion occurred in the "bunch" or "pile" which forms after a player running the ball is tackled. The surgeons very quickly got in the way of watching every pile with great interest and apprehension. The exact proportion between the injuries received in the open and in the pile, however, is not controlled by accurate figures. The number of injuries received in the games and in practice were proportionately about the same.

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Here follow a list of injuries received while playing football prior to 1905, and a list of injuries during 1905. Prior to 1905 there were 216 injuries; during the past year, there were 145.

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(1) Judging from our own experience, a very considerable number of the so-called bruised shoulders must have been partial dislocations of the outer end of the collar bone.

(2) Judging from this year's experience and from conversations with the players, we believe that the figures under concussion is much too small.

(3) The same statement applies to fractured ribs.

(4) The nature of the injury to the kidney was not specified.

(5) These bruises were sufficient to keep the player out of the game.

(6) The character of the injuries was variable, but includes what is ordinarily spoken of as "strained back," which oftentimes leads to very marked disability for a considerable length of time.

(7) These were cases in which no cause for the synovitis was made out and does not include the synovitis following, for instance, a dislocated semilunar cartilage. The number of these cases was agreed by everybody to be much less than in previous years.

(8) In one case there had been a previous dislocation of the shoulder.

It must be accepted that the figures of the injuries received during the previous years are within the facts. The players were most of them extremely conscientious about answering the questions in the circular letter. On the other hand, the game appears to breed such a contempt for physical pain that many injuries which would appear severe to the ordinary individual were considered trivial by the players. For instance, one man, in answering the circular letter, answered the question, "How many injuries were received during 1905?" "Absolutely none whatever," although at that time he was being treated by one of us for a very large hematoma of the ear and had previously received a partial dislocation of the outer end of the collar bone, and an (unrecognized) fracture of the metacarpal bone. Our own record of the serious injuries of this year (1905), however, is complete.

The following general methods of treatment of the ordinary, acute injuries were adopted: There was almost no fixation of injured parts, except fractures and dislocations, throughout the entire season, as the men were anxious to return to play and it was our belief that fixation usually unduly prolongs the time of convalescence. In the ordinary sprains of joints and notably in the cases of acute knees, heat was used very extensively, either by means of hot bathing or by means of the "baking machine." A large part of the acute injuries were treated by massage, with most remarkable and satisfactory results. We had, almost throughout the season, the attendance of a most efficient masseur, whose work was highly satisfactory. When a sprained or injured joint was unusually tender, partial fixation was accomplished by means of compression bandages, but in no case of joint injury was there fixation by splints, and in only two cases of ruptured muscle was complete fixation carried out. For partial fixation we used a heavy layer of sheet wadding surrounded by the so-called "Ideal" bandage, which was found extremely satisfactory, comfortable and efficient.

Certain classes of injuries were common and these are mentioned under special headings.

Head injuries.--Cases of concussion were frequent, both during practice and games. In fact, but two games were played during the entire season in which a case of concussion of the brain did not occur. There were several noticeable features in these cases. Frequently, the fact that a man had received a serious head injury was noticed by the surgeon from the side-lines before it was recognized by the players. This was due to the fact that a player might, apparently, automatically run through a considerable series of plays before his mates noticed that he was mentally irresponsible. The mental state of the players who had concussion was variable, some being highly excitable and hysterical, others merely confused, and in a few cases, knocked completely unconscious. In every case there was a certain loss of memory, both previous and subsequent to the injury. The loss of memory previous to the injury varied from a few minutes to a week. In all cases also there was a loss of memory as to the facts occurring for a variable time subsequent to the injury. For instance, it was common to hear a player ask if he had played the first or second half of the game. In all cases the loss of memory was greater at first than it was after a few hours. For example, the man who had lost his memory of events which occurred for a week before the injury, ultimately got to a point where he remembered everything up to within an hour or so. Players who had had concussion were at once carefully examined to exclude the possibility of middle meningeal hemorrhage and, during the earlier part of the season, were sent to their rooms or to their homes, with a companion, with strict orders that they were to be left alone at no time until noon of the following day. Later on in the season this method not seeming sufficient, the injured men were in every case compelled to go to the infirmary, where they remained over night. These precautions were taken to avoid the possibility of the occurrence of the middle meningeal hemorrhage with delayed symptoms. One case of middle meningeal hemorrhage did occur.

Concussion was treated by the players in general as a trivial injury and rather regarded as a joke. The real seriousness of the injury is not certain. Our own experience with the after-effects of the cases if not sufficient for us to draw any definite conclusions, but from conversation with various neurologists, we have obtained very various opinions in regard to the possibility of serious after-effects.

Dislocation of the outer end of the collar bone.--Partial and complete dislocations of the outer end of the collar bone were extremely numerous and were received in a variety of ways, some while tackling in the open, but the greater number of them were caused by the players having one shoulder caught in the pile with a mass of men fall in upon the unprotected shoulder. In but two cases was the dislocation a complete one, and in one of those cases the player received it very early in the game and finished a twenty-minute half with the collar bone and the scapula entirely separated. He was extremely fortunate to obtain no more serious results. One player on the second eleven played throughout the entire season with a complete dislocation received during a former season.

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[Here follow, with drawings, certain technical descriptions of injuries and their treatment.]

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Fractures.--The number of fractures received was considerable although nearly all were of minor severity. In almost every case the fractures were x-rayed. In many cases the men were allowed to play after receiving fractures, at a time when patients ordinarily would be willing to protect themselves, although in every case the players were very carefully guarded by special apparatus. In no case did a man who had been allowed to play a relatively short time after the receipt of a fracture receive a refracture.

Ruptured muscles.--These injuries were common and affected either the quadriceps extensor of the leg or the hamstring muscle. Ruptures of the quadriceps were especially common among the heavy men and in many cases were due apparently entirely to the muscular exertion of quick starting. In some cases and especially in the severer ones, the injury appeared to be due to a violent blow upon the thigh of a man running at speed with the muscles tense. Ruptures of the hamstring muscles, which are also common among sprinters, were in every case due to muscular exertion alone. These cases were treated by heat and massage and moderate exercises, such as walking. In two cases, however, the injury was so severe as to require fixation by splints.

Sprained ankles.--The injuries of this type were not, on the whole, severe, and in no case was a player kept out of the scrimmage for any considerable length of time. The ankles were treated by heat, massage and by strapping, although in one case a special apparatus, somewhat resembling a valgus shoe, was worn by a player throughout the greater portion of the season.

Synovitis of the knee.--These cases, except those due to a loose semilunar cartilage, were not numerous, and were treated by heat, both hot water and baking, by massage and by compression. The results obtained by these measures were surprisingly good and the time out of play was extremely limited.

Broken Noses.--In practically every case there was a fracture, not only of the external but of the internal nose, and all those cases were sent to a nose specialist.

The opinion of the players was that the injuries received were, on the whole, not severe. The real severity of the injuries, however, may be estimated in a number of ways:

(1) By the length of time during which players were incapacitated from taking part in the game. In answer to the circular letter the players stated the number of days that they had been kept out of the play by their injuries. The aggregate number of days during which players were incapacitated previous to this season was 864. The aggregate number of days during which players were kept out of the play during the season of 1905 was 1,057 days, that is an aggregate practically of three years. In regard to the apparent excessive amount of incapacity during the season of 1905, it must be borne in mind that players who had received injuries were not allowed to play until they had received the permission of the surgeon in charge, and, as has already been stated, great caution was exercised in keeping men out until they were thoroughly fit to play.

(2) Another index of the severity of the injuries is the number of days that players were kept away from scholastic or college duties. From the answers to the circular letter it appears that previous to 1905 players were kept away from school or college a total of 128 days; during the season of 1905 they were kept away from college duties 175 days. These figures are based upon the players' own written statements but have not been varified by the college record and probably do not represent more than the facts.

(3) Another index of the severity of injuries is shown by the amount of surgical supplies which were required during the season to properly dress and take care of injuries. To cost of those supplies for the past season was (including the sterilizer which cost about thirty dollars) two hundred and twenty dollars.

A final index is the answer of the players as to whether their recovery from injuries was complete, at the time the circular letter was sent out, a few days after the close of the season. One hundred and ten answers were received to 150 letters, and of those 110, 35 acknowledged that they had not entirely recovered from their injuries at that time. Besides those 35 who acknowledged that they were still suffering from a certain amount of disability or discomfort, it is known to us that many of the men who said that they were entirely recovered are suffering from injuries of more or less permanence. For instance, one man said that he had entirely recovered "except for a slight loss of vision." Another said that he had completely recovered "except for a slight dullness in the side of his head, with a bloodshot eye." Another reported that a loose semilunar cartilage was "absorbing," but "still in evidence." No one seemed to be in a position to settle with certainty the question as to whether there is any possibility of later effects from concussion. Many of the joint injuries are of such a character as to be likely to be progressively worse and many of the injuries to the shoulder are certain to cause some disability in later years.

The question arises, Is it possible to avoid these injuries as the game is now played? Many of the players claim that many of the injuries are avoidable. This year special precautions were taken to avoid the occurence of injuries. Men who were known to be candidates for the squad were notified early in the summer to begin to get into good physical condition before reporting for football in the middle of September. The scrimmage was not begun as early this year as is usual, in order to harden the men up as much as possible before the violent work began, and special pads and armor were provided in sufficient quantities to protect the players as far as possible. In spite of these special precautions it is claimed that the number of injuries was excessive. It was noticeable that the injuries came