What does language have to do with underestimating medical conditions? A whole lot. Read here how “punch drunk” evolved from a derogatory term to being the namesake of chronic head trauma – and why it’s important for medicine today.
One must call a spade a spade: Medical history shows that trivializing language and imprecise definitions can lead to underestimating severe diagnoses and clinical pictures – especially in the beginning of their clinical life cycle – or to regard them merely as symptoms of other, already known and established conditions. What is currently happening with the struggle to destigmatize psychological conditions that have long been treated in obscurity, unfortunately, also has a long tradition in neurology.
Language can be a great help, but also an indicator for underestimated symptoms and diagnoses. This can be seen impressively in the history of sports slang and its impact on modern medicine.
“Were you dropped on your head as a baby?“– sayings like this are deeply anchored in everyday language. However, the tendency towards this kind of metaphor already occurred in the 20th century. At that time, the term ‘punch drunk’ was just as widespread as the associated condition. Terms with similar connotations, such as slugnutty or punchy, were part of everyday language and arose primarily in the working class in the U.S. and Great Britain to make fun of the mental capacities or physical abilities of people who probably “got too many blows to the head.” The so-called punch-drunk slugnuts were accordingly characterized by mental deterioration, fatigue, irritability and slurred speech.
These derogatory terms connoted the repeated blows to the head, which we now know can cause severe neurological conditions such as chronic traumatic encephalopathy (CTE), with being a loser. This is also discussed in a recent publication by Prof. Stephen T. Casper, history professor at Clarkson University, called “Punch-Drunk Slugnuts: Violence and the Vernacular History of Disease”. He describes the phenomenon as follows: “The discovery of disease and its medicalization ran straight into a countervailing belief about losers — losers in boxing, losers in life, losers in general. To medicalize such individuals was to fly in the face of a culture that made them jokes. Yet a subculture began to emerge around pathological understandings: first in medicine, then in journalism, then in the courts, and finally with patient accounts about illness.”
The slang that emerged primarily from the working classes, referring mainly to athletic losers and people failing in life, also found its way into medicine early on. In 1928, the term punch drunk appeared as the title of an essay on brain injuries written by Harrison Martland. In the 1930s, the term increasingly found its way into medical essays and writings. “In a 1936 essay entitled Punch Drunk, the psychiatrist Edward Carroll observed that there was a ‘clinical syndrome of frequent occurrence among boxers, something they called punch-drunk, punchy, goofy, slap happy, cutting paper dolls, or slug nutty.’” Carroll added that doctors used the terms traumatic dementia or traumatic encephalopathy, but observed that punch-drunk seemed most descriptive.
Later, the syndrome would be named CTE. However, for a long time, the disease failed to gain acceptance as a serious medical diagnosis. “The disease instead slipped into cultural ambiguity and linguistic ambivalence, remaining a matter for humor, slur, innuendo, and libel rather than a provocation to public awareness about the dangers of normalizing brain injuries”, Casper said. Punch-drunkness was to some degree considered an indispensable evil in certain sports; it was just part of the game. Especially in contact sports like football, soccer, and, of course, boxing.
It wasn't until the 1950s and 1960s that medical experts began to analyze the lasting damage of traumatic brain injuries in boxers – and concluded that the medical concerns were overblown. Very few athletes' fates were documented at the time.
The downplaying of head injuries in contact sports goes hand in hand with the prevailing view of masculinity at the time. Athletes had to endure the pain; if they were unable to do so, they were not considered real men. Casper argues that a critique of the trivialization of the injuries and the accompanying chronic brain injuries would have simultaneously been a critique of the culture of the time – and therefore would not have been accepted.
The medical historian classified the history of neurodegenerative diseases as “a disease population experience that fought against its own discovery” and pointed out that the downplaying of repetitive head injuries resulting from impacts in sports continues to this day.
It is only in more recent years that the influences of repetitive traumatic brain injury in sports are being studied in depth. By the early 2000s, the issue surrounding sports and head injuries had arrived in (medical) society. “The intervening years had seen a linguistic change as well. Impact-associated neurodegenerative disease acquired the hallmarks of an emerging disease, one whose growing visibility implied its increasing anecdotal discovery — one patient at a time”, Casper explained.
Football has enjoyed ever-increasing popularity and accordingly received more extensive media coverage; something similar happened with soccer. The sports also became more violent, according to media observations. “Whereas early on chronic traumatic encephalopathy and its associated slangs and slurs—and indeed those who suffered from the disease – had existed on the cultural margins, by 2019 a variety of publics took the condition’s medical meaning for granted”, Casper explains in his analysis. Football's violent nature may well indicate a large incidence of chronic brain damage, but “one gets the sense that football fans, including the sports medicine establishment, don't want to know that.”
Cultural and linguistic developments in recent years have also had a significant impact on the language used in sports and medicine alike, and it continues to evolve. Casper gives an example: “At the 1978 Dean Martin roast of the American footballer Joe Namath, a figure named ‘O. J. Simpleton’ said, to many laughs, that he had taken all the injuries necessary so that Namath could shine on the gridiron. Simpleton said that he had the same concussion for fifteen years. Twitching and crossing his eyes, he explained: ‘My speech is...sl...my speech is sl-...slurred...dizzy spells...and I can’t, hic, walk straight.’ It was a familiar joke, though this may have been the last time it was made.”
These linguistic and cultural ways of dealing with a serious diagnosis explain why it was not perceived as just that for such a long time and reinforce the importance of calling a spade a spade so as not to trivialize it. All the signs would have been there from the beginning to see these clinical pictures as the serious diagnoses they actually are. But “the illness produced symptoms that, paradoxically, prompted its denial, challenged its discovery, and permitted questions about the veracity and reliability of its sufferers,” Casper says.
Bildquelle: Pablo Rebolledo, unsplash
