Representations of Values in Britain and America

The concept of malingering resulted from nineteenth-century social and economic contexts in Britain and America. Suspicions of poverty were high. Relations between employer and employee were changing. Industrial accidents that caused traumatic injuries fell into a grey area of jurisprudence as new workers compensation laws took shape in statutes, torts, and contract negotiations.Reference Friedman and Ladinsky ¹⁶ Lawyers for plaintiffs brought actions in the nineteenth century. Employers resorted to a common defense that emphasized the “contributory negligence of the employee, assumption of risk, and common employment.”Reference Epstein ¹⁷ Was the victim blameless, a question which meant that the plaintiff’s character, associations, and legitimacy deserved investigation. ¹⁸ Whether the injured patient was a hereditary defective was also considered a legitimate question. Malingering filled these special rabbit holes. As historian Roger Cooter has shown, malingering became a medical and psychological problem during the First World War,Reference Cooter, Cooter, Harrison and Sturdy ¹⁹ yet the malingerer emerged as a category of social existence from the mid-nineteenth century.

Inevitably occupational injuries implied head injuries and brain injuries. TBIs brought immediate incapacities and potentially worrying longer impacts.Reference Casper ²⁰ Nineteenth-century medical publications and public information made this clear from the mid nineteenth-century on. Personal character and contributory negligence were always central issue. How injuries occurred and to whom heightened the importance of context decisively.Reference Erichsen ²¹ The context mattered for assessing prognosis and claims of permanent disability. Doctors’ roles in providing those diagnoses and prognoses implied vast powers. Doctors increasingly made decisions about legitimacy that mattered materially in patients’ futures. Insurers, relying upon clinical judgment, appear to have felt themselves besieged by cases of subjective symptoms, fraud, and malingering. Payouts also corresponded often with what cynics called miraculous cures. ²²

Brain injury legitimacy and expertise occurred in contexts with normative class pressures (highly variable across Britain and America and generationally) and economic deployments that changed with industrialization and warfare. Stakeholders’ interests in Britain and America were often finely tailored to accord with the letter of the law. In a quite significant sense, concussion in the courts was tantamount to the making of scientific knowledge throughout courtroom dramas, a fact that left an indelible mark on the science and medicine of TBI. While many clinicians and investigators sought to insulate themselves from those deep influences, each judgment that required expertise made concussion science and medicine that much more uncertain.

The Intersections of Traumatic Brain Injury: Class, Gender, and Stigma in the 19th Century

The spectacle of the malingerer evoked significant prejudice against chronic patients, and TBI made these intersections highly visible in the nineteenth century and after. Two instances suffice to illustrate the broad trend in nineteenth century Britain and America. Consider the August 1878 issue of Pall Mall Gazette, an evening newspaper published in London, which took up the troubling subject of the malingerer “or simulator of disease.” Published under the ominous title “Sketches from Shady Places” the author described unpleasant figures at “common lodging-house,” or on the “sick-list” of many a reputable employer, haunted London dens and preyed “on the public.” The hospitals were altogether too pleasant, the author remarked. To “the man of soft and indolent disposition,” the taste of “hospital life” provided the purest of temptations:

The malinger, the author stated, was a beggar, a corpulent fellow likely surviving on the labor “of his daughters — a pair of weak-looking girls, seamstresses”, an indolent, and indeed the tendency ran “in the blood” for “hereditary paupers” formed a class in the workhouse populations “all of them inveterate malingers.” ²⁴

The source shows a whole worldview manufactured in an instance. It displays resentments typifying class relations in British and American industrialization, a time when with hindsight it should be recalled that: “Social insurance was unknown. Local poor relief was cruel, sporadic, and pinchpenny. Institutions for the helpless were indescribably filthy and heartless … the whole system was shot through with … an inordinate fear of the spread of idleness and a perverse notion that pauperism generally arose out of the moral failings of the poor.”Reference Friedman and Ladinsky ²⁶ But the argument I am offering is that these representations would be as familiar now as they would become in that period, and that far from being accurate, they signal prejudices that shape structures determining clinical and legal encounters. Laziness, poverty, obesity, sinful licentiousness, mentally illness, and cowardice — all pointed to the conclusion that it was easy to feign sickness for monetary reward.

Women TBI patients experienced these matters in similar ways.Reference Oppenheim ²⁷ Consider this second source. In 1886 a case history in the United States appeared in the Boston Medical and Surgical Journal. The source points to the way normative attitudes could result in self-injurious behaviors. The author Arthur H. Nicols recounted how in 1884 a freight train flipped over tracks and tumbling over brought up against this house, knocking a hole in the side-wall of the kitchen where Louisa Russell “was at the time engaged in her ordinary housework.”Reference Nichols ²⁸ The box car did not destroy the house. Nicols noted that Russell had “not been thrown down, rendered unconscious, or even nauseated” which indicated that “the blow received was not of great severity.” Indeed “there was no satisfactory evidence to show whether she was in reality struck on the head.”

Nicols explained that the chief symptom complained of and seen by her personal physician “sixty-five” times was headache. The suspicions of others are certainly noteworthy. Nichols wrote: “The exercise involved in hanging out clothes must be pronounced at least injudicious, if there existed, as it assumed, any lesion of the brain. To interpret, however, this indiscretion as evidence of fraud or exaggeration, would indicate an imperfect knowledge of the eccentricities of the patient.” ³⁰ Nicols explained that the case appeared to be “concussion of the brain.” The cause of the patient’s long term problems was that “the real nature of the trouble was not for a time suspected, and consequently absolute rest, the essential element in the treatment of such lesions, was not enjoined.” It would be impossible, Nicols said, “to assume this to be a case of malingering” because “stimulation of organic brain trouble is not admitted as within the range of possibility by any treatise on malingering.”Reference Nichols ³¹

These two cases reflect schematically, as I have shown elsewhere with more detail, a commonplace reality that shaped personal injury law, workplace compensation, insurance claims, and after World War I public policy on psychiatric and psychological injuries suffered during warfare. These coincidently often overlapped with the burden of traumatic brain injury that had left no visible mark on the soldier. The case of Louisa Russell personalizes rather sharply the way that the expectation of the suffering individual was that they would carry-on in their houses but that also the fact of their continued efforts could result in worsening of symptoms and suspicion of exaggeration. Public and private worlds made such distinctions. TBI patients routinely encountered a limiting argument in court that if they had the capacity to argue and advocate for themselves then the conclusion could only be that they were better than they believed. Those unable to advocate for themselves or those seen contributing effort to their households thus confounded the sick role — the expectation that people who are sick will be sick in ways that confirm illness meant the TBI patient with persistent symptoms fit no specific category of invalidism.

The Intersections of Traumatic Brain Injury: Gender, Sport and Stigma in the 20th Century

Sport plays a peculiar role in the history of TBI and stigma, because the frequency of presumed mild brain injuries shapes these constructs but the dangers of sports are equally worsened by normative assumptions about the ability of people, mainly men, to take punishment with their bodies. These facts are seen clearly in the entangled history of TBI and sport in twentieth century Britain and America. As Bachynski has beautifully noted in her study of boys and American football, the pressures to discipline the body to survive and play through its pain is packaged by domestic understandings about gender roles in American society in which boys are meant to differentiate themselves from girls through pain and militaristic pageantry.Reference Bachynski ³² The same pressures existed in Britain during the period of Bachynski’s analysis in rugby and soccer, but they have a longer history, dating from the nineteenth century when the absence of fathers off on colonial pursuits demarcated that sports would teach boys to be men.Reference Burstyn ³³

Collision sports proved remarkably adept for heightening the ability for people to deny the consequences of injuries they deemed minor. A degree of manly apathy and chumminess in collision sports about these injuries inculcated in sports playing men stoicism and reticence about the seriousness of the injuries, and as these young men came of professional age, it seems likely that more than a few viewed similar injuries suffered in other contexts with similar apathy and bravado. In other words, reticence about injury created a culture in which playing through pain in sport taught stoicism about injury wherever and however it occurred.

Two chapters in a 1969 volume entitled The Late Effects of Head Injury brings these matters into the open.Reference Walker, Caveness and Critchley ³⁴ One study by John B. Cook explored the effects of minor head injury sustained in sports resulting in postconcussion syndrome, a collection of persistent, often debilitating, symptoms following longer after a head injury than would normally be expected. Cook reported that something akin to postconcussion symptoms were seen in head injured sports players but noted that they were “shortlived” and “absence from work is only occasional and is not prolonged.” Cook’s conclusion from this study was that it implied that hospitalization of non-sports cases could result in poor recovery and lead to an unshakeable conviction of unfitness for work. He concluded: “The postconcussional syndrome with its stereotyped and persistent symptoms relates neither to concussion or brain injury, nor possibly even to the frightening aspect of the accident; its existence depends upon by whose hand the injury was caused.” Blame avariciousness, he moralized.

It is important to see that Cook’s argument could not have been viewed as farfetched. Injuries in sport were so common that whole books devoted to the prevention of athletic injuries had already been published for decades by the time he elaborated his argument. He was also toiling familiar British soil, pointing for example to neurologist Henry Miller’s coinage of “accident neuroses” as a pithy means of situating patients who allegedly could not be as hurt as they imagined or purported.Reference Miller ³⁵ Yet some thought about the way that British sports had evolved by the 1960s would make it fairly easy to see that the coercive pressures on sportsmen were vastly larger than those on other populations. In this sense, Cook was unable to see through the limitations of his own cultural preferences. From the adulation of fans and families, to the pressures to represent national and working cultures, to the love of teammates in a martial sense, and indeed to the threat of being replaced by a younger player, the average elite athlete in the 1960s and after had good reasons to play through injuries and to deny the seriousness of neurological symptoms hidden from view by the skull. Footballer’s migraine might have been annoying, but it was not necessary to tell anyone about it and it could be treated with narcotics. Who would know?

Sport thus shaped the representation of non-sport injuries by ignoring the way in which sport created, celebrated, and concealed self-harm. This fact became a source of stigma non-sport TBI patients, particularly in the courtroom. The second chapter investigated here was by Sir Frederick Lawton titled “An English Judge’s View of Some Medical Problems to be Met in the Courts” explored the various claims made by workers and others in accidents — symptoms like headaches, inability to concentrate, decreased libido and the like.Reference Lawton, Walker, Caveness and Critchley ³⁶ Lawton appears to have been beyond contemptuous of such claims. He complained about clinicians’ courtroom testimony, remarking: “Need you accept as often as you do what the patient tells you?” ³⁷ His suspicions, he noted, were shared by the infamous British neurologist F. M. R. Walshe, who had often asked rhetorically in court in defense testimony, who “has ever come across functional disorder without clinical signs of lesion in jockeys or professional footballers” who “frequently have knocks on the head while following their employments.”Reference Lawton, Walker, Caveness and Critchley ³⁸ In this way, then, masculinity in sport became a structural determinant of health and healthiness in non-athletes. The fact that normal people in their normal lives had little in common with young, strong, and coerced athletes became a reason for distrusting them rather than distrusting the atmosphere of sport in which the downplaying of harm implied a gender identity.

Stigma about malingers in normal population worked its magic on sport too. The familiar tone that Lawton and Cook adopted became a significant means of questioning athletes’ pain. Consider one contemporaneous American example from a profile of American footballer and fullback Jim Brown published in Ebony Magazine in 1964. Reflecting on Brown’s stoicism, club house director Morris Kono stated “He never asks for thing. On a cold day you have to give him a coat. I don’t even know if he wants it. He never takes a sip of water during a game. You never know if he’s hurt. He doesn’t complain. The guy was a Spartan the day he showed up and he’s exactly the same now.”Reference Poinsett ³⁹ Brown’s wiliness to work was noted by the reporter who then described a moment when Brown “suffered a brain concussion in a pileup and spent one quarter on the bench.” In that circumstance, Brown recalled that his “coach hinted he was gold-bricking.” Brown remembered that he couldn’t remember the plays and recognized after the fact that his coach basically “didn’t seem to care if you lived or died, so long as you played.” ⁴⁰

The ability to even recall this episode could well have been deemed evidence that Brown was malingering, another word for goldbricking. More likely, however, is that this anecdote captures a whole different world in a moment. It makes clear that athletes are re-exposed to harm by sports doctors, coaches, trainers, and other responsible authorities downplaying that harm and by intimating a comparison with the shadowy figure of the malingerer or simulator. In 1969 two clinicians suggested that such malingers were familiar to high school coaches and usually took the form of a boy who was scared to play but under peer and parental pressure to do so. In such instances, they argued, the nice thing to do was pretend with the boy that he was so injured it was necessary to retire from sport forever.Reference Schneider and Kriss ⁴¹ Athletes who did not or could not take the pain were considered too frail for the sport. No one challenged the notion that it was the sport that was in the wrong.

It is essential to see that in all of these situations a moral economy prefigured what Dominic Malcolm calls an axiological question.Reference Malcolm ⁴² The sporting world, a martial morality, required a particular kind of body calibrated for spectacle and its economic impacts, all of which were predicated on erotic desire, violence, and heroism. In the medical world, a morality of healthiness and stoicism, required a body that desired its own health and denied a place for itself as a burden on others and called this quality of life.Reference Burnham ⁴³ In the legal domain, the existence of these bodies pointed to virtues of stoicism and healthiness that framed economic realities of necessity, responsibility, liability, and settlements. Sloth and greed were moral hazards faced by all in all of these domains. To look at this with competency, it should be clear that the structures of this practice of stigma promoted self-harm by making people overwork themselves at the demand of others or by downplaying the harm they had experienced for the reward of not living up to the stigma itself. In order to see these harms, it is necessary to name and understand these stigmas.

What to do? A Proposal to Aid Structural Competency on TBI in Sport and Beyond

In this short essay I have sought to explore the ways stigma, traumatic brain injury, and sport compound and unify risks across several social and professional domains. Structural competency in brain injury research requires recognizing that these long histories of courtroom battles, cultural concern about fakers, shirkers, and effeminacy, and economic resentments created through the compensability of workplace injuries, place large burdens on TBI patients to prove their own clinical and legal legitimacy. Many of them end up trapped in two ways. They are either too injured to address the burden and cannot. Or they possess the personal wherewithal or support structures to call attention to their difficulties but by so doing make experts question whether they are as bad as they report. In this area of clinical care and law, working at the least to make these social contexts and social pathologies structured in the clinical and legal system visible for all is good social medicine, not least because it invites clinicians particularly to question their own assumptions about what sick people might have to do in order to survive in a society with scant resources dedicated to chronic patients daily needs and support.

Many of the central themes of this essay are extant broadly in the history of neurology. These concerns have revealed themselves periodically in the treatment of nervous diseases women, in the cultural understanding of post-traumatic stress disorder, and in the way that harm is downplayed in the manufacturing of uncertainty. In the world of traumatic brain injury they have evoked numerous stigmatizing labels over the years in psychology and medicine, from malingering to iatrogenic disease to miserable minorities. These characteristics of stigma in this context are that they remain structurally determining of health and well-being and produce unhealth in myriad ways, including public toleration of violence, acceptance of unnecessary exposure to head impacts, and an expectation that little about brain injuries will be discussed clearly and transparently.

How should researchers in social medicine respond to the challenge of the circularity of harm posed by the story elaborated above? In the essay that follows this contribution, a collection of authors adopt a position statement on consensus documents about sport concussion. They argue for person-centered and player-centered guidelines that adopt precautionary recommendations and use strong transparent languages about risk as a way of breaking this axiological cycle. Furthermore, the signatories call for a reflexive turn in evidentiary standards by arguing for strenuous disclosure of conflicts of interest, sources of bias and omission, and radical transparency about risk. In offering this position statement, the signatories seek not only to redress the harm that is baked into these decontextualized positions, but also to remedy a now century long collection of circumstances and facts that have culturally positioned these consensus guidelines and other documents like them in ways that deny the material circumstances in which elite and non-elite athletes play and the ways their experiences shape the lives of normal TBI patients. By asking researchers to confront their own values and preferences and sources of motivated bias, the essay that follows proposes that it is possible to break down axiological barriers that perpetuate harm across the whole traumatic brain injury space, including sports but transcending them as well.