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A seemingly minor collision in a sport like football can result in serious, even fatal, injuries, as described in this story.

Fourth-Down decision-making

His star lineman just needed routine clearance to return to play, the high-school football coach assured the doctor. But the neurologist quickly realized the situation would be a much more complex call. This excerpt from a book by a DMS alumnus describes events that took place some years ago, but tackles issues that are all too current.

By John E. Castaldo, M.D.

I was sitting in a small cubicle on the locked-down unit of the Behavioral Health Center at my central Pennsylvania hospital, across from a middle-aged man who was telling me in a flat, hollow voice, "Satan makes me do horrible things." Nine years earlier, this man had jumped from a bridge and fallen into a deep coma, from which he'd recovered thanks to modern trauma care. More recently, he had held a nurse at knifepoint, partially slicing her neck before letting her go, critically bleeding but still alive.

His psychiatrist had asked me to evaluate his neurological status to see if he could withstand electroconvulsant therapy, which can sometimes break the hold of long-standing, tenacious depression.

We had just started talking when my beeper vibrated on my belt. Flipping it out to look at the number, I recognized it as a STAT, or urgent, page from my office. Excusing myself from the isolation room, I went out to the hallway to call my office manager.

"Dr. Castaldo, we just received an urgent call from a Coach Peterson at Parkhurst High School," she reported. "He said he needed to speak to you right away."

"I don't know a Coach Peterson," I said, slightly mystified, "Did he say what he wanted to talk about?"

"No, only that it was extremely important. Do you want to call him back?"

"Sure," I replied, pondering momentarily whether Coach Peterson's needs were truly more urgent than those of the possessed man I'd just left. But not wanting to second-guess anyone, I punched in his number and listened to the phone ring.

"Athletic Office, Coach Peterson speaking."

"Yes, this is Dr. Castaldo from Lehigh Valley Hospital returning your . . ."

"Oh, yes, yes, Dr. Castaldo, I need to speak to you." His tone was grave and tense. "Do you follow high-school football?" he asked.

I felt a flash of impatience and disorientation. This was an emergency call? I had felt safer back in that padded room than I did standing here in this open hallway, talking in riddles with a stranger.

This story is excerpted from a book titled Uncommon Wisdom, by John E. Castaldo, M.D., and Lawrence P. Levitt, M.D.—from a chapter by Castaldo called "The Boy in a Giant Man's Body." Castaldo is a 1976 graduate of Dartmouth College and a 1979 graduate of Dartmouth Medical School and did his residency in neurology at DHMC. He is the chief of neurology at Lehigh Valley Hospital in Allentown, Pa. The events described here are all true, but certain details have been altered to preserve patients' confidentiality. The book is copyright 2010 by John Castaldo and Lawrence Levitt, and this excerpt is reprinted by arrangement with Rodale, Inc., of Emmaus, Pa.

"No, sir," I replied as evenly as I could. "I confess that I do not."

"Well, if you did, you'd know the name Bobby Parker, one of the greatest linemen ever to come to the game of high-school football."

"Is that Bobby Parker of Harrisonville—Rick and Margie's son?"

"Yup, the very one."

An image of a chunky, cheerful boy materialized. "He used to play with my boy, Mark, when they were in elementary school," I recalled, "and the family goes to my church. So, yes, I know who you mean."

"Well, let me get right down to it, Dr. Castaldo. I'm sending Bobby in to see you for a neurological exam. A couple times in the last month, he's gotten his bell rung—you know, gotten his head hit hard enough to be stunned and have to come off the field for a bit. The rule books say that when that happens, he needs to be seen by a neurologist." The coach's voice dropped a notch lower. "But just between you and me, Doc, I don't think there's anything wrong with him."

"Oka-a-a-y," I responded, trying to decipher what Coach Peterson was getting at.

He seemed to pick up on my confusion. "Look, Parkhurst High School is headed for the state football championship this year," he said. "We depend heavily on Bobby Parker. He's a phenomenon."

When I didn't immediately respond, he cleared his throat. "Now, look, of course I don't want to take any chances with the boy's health," he said. "But I just wanted you to know this is more a formality than a real problem, and I don't see any reason why the boy can't continue to play ball."

This late-1970s Dartmouth football game dates from about the time of a sad incident that two Dartmouth neurosurgeons analyzed in a landmark journal article.

I'd heard enough. "I'll examine Bobby carefully, and I appreciate your concern," I said, thinking far less gracious thoughts. "Good-bye."

After hanging up, I finished up my evaluation of the psychotic, satanic man and then walked back to my office to write up some reports. There, propped up on my desk, I saw a handwritten note from my secretary: "Rick and Margie Parker called. Can you call them back today?"

More urgency, I thought, but waited until after 5:00 p.m. to return their call. Rick picked up quickly and summoned his wife to join us on the other line.

"Hey, John," Rick said brightly, as though we were the best of friends. "Well, hello there," his wife chimed in from another phone.

"We're pleased that you're going to be seeing Bobby," Rick continued. "Your office gave him an appointment for next week, but we were hoping it would be possible for you to fit him in tomorrow."

"Oh, my goodness," I said, immediately concerned. "Is he not doing well?"

"Oh, no, just the opposite," Rick replied. Once again, I felt a flash of confusion. So then why the urgent call? "You see," he went on, "Bobby is real important to the Parkhurst football team, and they have a big game coming up next week. He wants to get back in the game as quickly as possible, and I think this neuro exam is just a formality of the high-school athletic rule book."

There was that word again: "formality." I wasn't used to examining patients as a formality, especially urgently. The conversation was feeling increasingly alien.

"Of course, we would never want anything bad to happen to our boy," Margie assured me.

"He means the world to us, but football means the world to him," Rick said, his voice full of pride. "You know, he has a shot at a full scholarship to Notre Dame or one of those Ivy Leagues."

But I wasn't interested in Bobby Parker's college prospects. "Can you give me an idea of what happened to his head?" I asked, with an edge to my voice.

Rick hesitated for a split second. "Well, this month he got hit pretty hard in practice and got his bell rung for a few seconds," he admitted. "Then in a game he got hit hard again. You know, everyone is gunning for him because they know if they take him out, they can win."

"Any other incidents where he was hit in the head and stunned enough to have to come off the field?" I asked.

"Well, it might have happened again in a double-session practice," Rick conceded. "But I think the last time he was really dehydrated and probably just blacked out from heat exhaustion."

"So you're saying that Bobby had three possible head concussions within one month?"

"Well, that's what people are worried about, but I don't think they were real concussions," Rick responded, a note of defensiveness creeping into his voice. "You know, I played in college and got my bell rung all the time without any problems." I remembered then that Rick had gone on to be a star halfback for a pro football team.

"But we do want what's best for our boy," Margie interrupted.

Rick, however, was determined to have the last word. "Still, we thought you should know he looks fine to us at home, and we don't see any strange behavior to indicate any kind of neuro injury."

The two phone calls were deeply disturbing. The adults in Bobby's life were assuring me that they were trying to help him. But I was troubled by how determined they seemed to be to manipulate my opinion in view of the strong possibility that he had sustained multiple concussions over a short period of time.

"Okay, okay, I think I've got an idea of what's going on. Thanks for the call," I said abruptly, wanting to end this call as much as I'd wanted to cut short my conversation with the coach earlier in the day. "I'll see Bobby over my lunch hour tomorrow, and we'll talk more then."

The two phone calls were unusual and deeply disturbing to me. On the one hand, the adults in Bobby's life were assuring me that they were trying to help him. On the other, I was troubled by how determined they seemed to be to manipulate my opinion—especially in view of the strong possibility that Bobby Parker had sustained multiple concussions over a short period of time. These events took place all of 15 years ago, but even then there was increasing concern about the cumulative effect of repeated head trauma.

Before I went home that evening, I went to my files and pulled out an article published a decade earlier, in a 1984 issue of the Journal of the American Medical Association (JAMA). In that article, the authors—Drs. Richard Saunders and Robert Harbaugh, neurosurgeons at Dartmouth—had coined the expression "second-impact head injuries," now known as second-impact syndrome. The article had brought to national attention the dangerous nature of mild but repetitive concussive head injuries. It was a case report of an Ivy League football player who had died a few years earlier following a seemingly minor collision during a football game at Dartmouth. I remembered the details of the sad event all too well, because on that terrible day I'd been the receiving medical resident in the Dartmouth-Hitchcock emergency room.

The unfortunate player was an extraordinary athlete. A 19-year-old freshman, he was already a star lineman for the team Dartmouth was playing that day. But a few nights before the Dartmouth game, off the field, he'd gotten into a fistfight with another athlete. According to witnesses, he had taken a blow to the head and had briefly lost consciousness when someone "sucker-punched" him.

On the third day following this apparently minor head injury, while blocking a running play during the game at Dartmouth, he'd butted helmets with a Dartmouth player in a seemingly routine collision.

The Dartmouth player had walked off the field, uninjured. But when the opposing player stood up, he moved unsteadily, as though he were drunk. Then, just before reaching the sidelines, he collapsed. As an ambulance rushed him to Mary Hitchcock Hospital, the emergency responders called in his status to the ER: "Deep unresponsive coma with fixed and dilated pupils." The ambulance crew reported that their patient had stopped breathing and that his respiratory function was being supported by a device known as an "ambu bag."

I was on the receiving end of that call and couldn't believe my ears. I had seen gridiron injuries, but they'd been mostly torn ligaments, twisted knees and ankles, dislocated shoulders, ruptured spleens, and the like. I'd seen many concussions as well, but little serious brain injury.

Upon the young man's arrival in the ER, I found his neurologic status to be as billed. An otherwise healthy, athletic Ivy Leaguer had taken a mild hit to the head and now was showing signs of severe brain injury. An immediate CT scan showed a terribly swollen brain, as if he'd been hit in the head by an 18-wheel Mack truck, not merely another athlete on the field of play. We called neurosurgery, and the young man was rushed to the operating room, where the top of his skull was removed to allow his brain to swell unimpeded. And swell it did, right out of his skull. In the intensive care unit, a sterile wet dressing was laid over his pulsing cerebrum in the hope that the swelling would subside and allow him to recover. But a few days later, this promising young man was declared brain dead and life support was terminated.

At first no one understood what had happened to this unfortunate young athlete. Then Saunders and Harbaugh wrote about the case to spread the word that a seemingly minor head injury could have an unexpected, disastrous outcome. If an athlete sustains multiple concussions within a short period of time, they wrote in their landmark JAMA article, there is an increased risk of sudden, elevated intracranial pressure that can progress to severe, sometimes fatal, brain swelling. When the lineman had butted heads with his opponent, he'd suffered his second impact within a few days; it was the cumulative effect of the two head injuries that had caused his death.

Many believe that it was this awareness-raising JAMA article which led to a change in U.S. football rule books that was aimed at preventing future such tragedies. The new rule mandated a neurologic examination of any young athlete who had sustained a head concussion—exactly the kind of examination that I was now being asked to make of Bobby Parker.

The trouble was that no one knew how athletes could prevent a further severe head injury except by avoiding additional concussions within a short period of time—in other words, by temporarily bowing out of their sport. Not only were young athletes, their parents, and their coaches often loath to do this, but there was still much confusion and misunderstanding about the phenomenon of concussion. There were no universally accepted medical definitions of concussion, nor was there consensus about the mechanism of a concussive injury. Many neurologists believed that it occurred when a hyperextended neck placed enormous stress on the brain stem, the structure that supports basic life functions. Research had shown that animals could survive tremendous force to a head and neck that were firmly supported but lost consciousness quickly if lesser force struck the skull when the neck was unsupported. Yet the Ivy Leaguer I'd treated had had a tremendously strong neck.

It was Dartmouth neurosurgeons Richard Saunders, left, and Robert Harbaugh, right, who in 1984 first highlighted what is now known as secondimpact syndrome. Awareness of the problem has since grown, though slowly.

And so did young Bobby Parker, whom I would soon examine formally, for formality's sake.

The following day I saw Bobby for the first time since he was in seventh grade. I remembered him as a big boy for his age, with outsized hands and feet and a tendency toward clumsiness that was normal for his age and growth stage. Now he was 16 years old and a junior in high school. When I looked up as he entered the exam room, I saw a young giant. He was six feet, eight inches tall and 285 pounds of solid muscle. His huge head was shaved military-style—close to the scalp on the sides and with a slight crew-cut on top. His broad jaw bore a five-o'clock shadow even though it was barely noon, and a thick Fu Manchu mustache curled his lips into a perpetual frown.

Below the neck, Bobby's body was a piece of massive sculpture. His arms were huge, perhaps as big around as most teenaged girls' thighs, with large, blue serpentine veins circling his biceps. His thighs were like tree trunks, with muscles sharply outlining his quadriceps as though Michelangelo himself had chiseled them in white marble. I tried not to stare, but as far as I could tell there was not a trace of subcutaneous fat on the boy's body.

Bobby's parents had nonchalantly followed him into the exam room. "Hey there, John," Rick hailed me. "Glad that you could take a look at our son here, because you know we all want to do the right thing." Once again, I listened to the father's story of Bobby's "minor" hits to the head, which sounded oddly rehearsed. What I knew for a fact was that during this season, Bobby had been helped off the field on at least three occasions, all of them in the last month. On each occasion, he'd been hit hard enough in the head to be temporarily taken out of play. It sounded to me as though he'd sustained three concussions, but his father insisted that his son had been "just stunned" or was perhaps "just dehydrated" and "fainty." His parents assured me that the boy's school performance continued to be good.

At this point, I asked Rick and Margie to leave the exam room so I could ask the boy to undress for a full exam and chat with him unencumbered by parental influence.

Once alone with Bobby, I couldn't help but notice that the exam room and its furniture looked like dollhouse miniatures next to him. I, too, felt suddenly diminished: Though I stand six feet tall and weigh more than 200 pounds, I'd never felt so small before. Looking at 16-year-old Bobby, I realized that he could easily pick me up, snap me in half, and toss my pieces over his shoulder with one hand. He was more than intimidating. He was deadly.

As an icebreaker, I asked Bobby if he enjoyed playing football, thinking the answer would surely be yes. I figured he couldn't help but relish the opportunity to talk about his feats on the field.

"I'm good at it," he replied. His voice was flat, disinterested.

"But do you look forward to games?" I persisted.

"I'm one of the best centers in the league," he said. "I'm hoping for a college football scholarship. I need to play," he said in a monotone, as he stared out the window.

"Nice stash," I ventured, referring to his mustache. For a moment, I thought I saw the Fu Manchu turn upward in a half smile before the frown returned.

I gave up on the small talk. "What happened on the field this past month, Bobby?" I asked gently.

"Nothing happened!" he snapped. In a flash, his muscles had tightened and his shoulders had lifted as though he were ready to throw a punch that could take my head off.

"Okay, then, Bob. What do people say happened?"

"I don't know and I don't care what people say," he muttered. For a moment his eyes darted to meet mine but then quickly retreated to stare at the wall above my right shoulder.

"I took a call from your coach and spoke to your dad and mom, who only want the best for you, as do I, Bobby," I gazed at him until, reluctantly, he met my eyes. "You know, some kids can get seriously hurt if they play too soon after a concussion. I've seen a very strong athlete die after a minor tackle on the football field."

He looked back impassively. I let the silence hang in the room, hoping he'd respond. But like the player he was, he waited me out.

"Some say you took some pretty heavy hits to the head and may have had a concussion and had trouble getting up," I said. "What do you think about that?"

"That's not true!" Bobby shot back defensively. "I never had trouble getting up after a tackle in a game. That was in practice and only because I let my guard down and got sucker-punched from the side."

"Okay, so what exactly happened?"

I could see the effort that it took for Bobby to simply talk with me. "We were doing double-session practice in the summer," he began, in a barely audible voice, as though he were recalling a memory from years before.

"We were in the hot sun for four hours working out. I got into an argument with one of my teammates at water break, and he decided to team up with a friend and try and hurt me at the next play." Now his voice began to gather a bit of energy. "So one guy hit me from the left while another speared me with his helmet from the right, and I went down for a minute. It was totally illegal and totally unfair."

Now Bobby was sounding like the kid he was: I detected a petulant whine in his voice.

"So how long were you out?" I asked mildly.

"I never said I passed out!" I was startled not by Bobby's words but by the abrupt change in his expression—from ordinary irritation to intense, thin-lipped fury. He seemed to be breathing harder.

I nodded as though we were carrying on a pleasant conversation. "Did the coach take you out of the next play?"

"I guess so," he said sullenly. "I had to sit out the rest of practice."

"Did you have a headache or any trouble remembering the plays after the hit?"

There was a small silence, then he said, "I don't know."

I took note of that and changed the subject. "Let's talk about the games," I suggested. "What happened there?"

"Well, in one I got creamed pretty hard in the head," Bobby admitted. "I guess I was acting strange after the play because the coach took me out for a while. But I didn't pass out!" he reemphasized.

"Did your head hurt?" I asked innocently.

"I always have a headache when I play football," he said through gritted teeth. "My dad tells me that's just normal."

I took some notes. "How about the other game where you got hit hard?" I asked.

"It was the Melrose game," he said, briefly covering his face with his hands as though he'd like to forget that one. "I went to block for the quarterback play, and three players came at me at once. Next thing I remember I was sitting on the bench. But I don't think I really lost consciousness because I got right up after the tackle. I think I was just dazed real bad and so angry at the three-on-one play that I blocked everything out of my memory for a while." He hesitated for a moment. "At least that's what my dad says."

"I'm concerned about something called the second-impact syndrome," I said, mentioning the college player I had seen all those years ago in the Dartmouth emergency room. Bobby's father was unfazed. "All I can say is that my bell got rung more times than I can count, and I'm no worse for the wear," he said.

I had no more questions about head injuries.

Next, I put him through my toughest neurologic exam, which he passed with flying colors. There was no sign of memory loss, speech difficulty, reasoning or judgment deficits, or limb weakness or numbness. His reflexes were normal. As far as I could tell, the most abnormal thing about Bobby Parker was his emotional state: He appeared to be either angry or deeply depressed, quite possibly both. During our conversation, his face was an expressionless mask, except for those few startling flashes of anger. As he slid off the exam table, he kept his eyes on the floor and muttered to nobody in particular, "This whole exam thing was a waste of time."

But I couldn't let him go without bringing up one more topic. "You're mighty bulked up," I observed casually. "How often do you lift?"

"Four hours a day—two in the morning before school and two at night after practice." Almost imperceptibly, he sighed heavily. "At least that's what I try to do, because my dad seems to think I need to."

"That's a lot of lifting," I said. "Why do you think your dad wants you to lift weights so much more than Coach Peterson?"

Bobby shrugged. "I guess he has bigger plans for me," he said.

A moment of silence hung in the room.

Then Bobby straightened his shoulders again and flexed his biceps. "You know, I'm the meanest, toughest lineman in the Valley."

I smiled at him. "No, you're not, Bob. You're just the playful big kid who used to play King of the Hill with my boy Mark a few years ago. Now you're just all bulked up!"

Before Bobby could stop himself, he flashed a toothy grin and I caught a twinkle in his eyes. For just a moment, I got a glimpse of the boy in that giant's body.

"Mark and I used to have some good times," he said, nodding, though he didn't ask how my son was.

"How are you doing in school?" I ventured.

"Great," he mumbled, turning away from me. Our moment of communion was over.

"So are you an A and B student?" I gently probed.

"Nah, C's mostly, but that's good enough for a football scholarship." He was speaking to the window.

While I left Bobby alone in the exam room to get dressed, I met with his parents again in my office, with Bobby's permission. "Everything looks all right," I told them, "but I'm concerned about something called the second-impact syndrome." I explained the syndrome and mentioned the college player I had seen all those years ago in the Dartmouth emergency room. Bobby's father was unfazed. "All I can say is that my bell got rung more times than I can count, and I'm no worse for the wear," he said, shrugging. "Bobby will be fine. He just needs to get out there and play ball." His wife wrinkled her forehead and squirmed in her seat but said nothing.

I told them that I wanted to do a few more tests and take some time to think about what would be best for Bobby.

"Whatever you say, Doc," Rick responded tersely.

Then I turned to a new subject: Bobby's physical massiveness. "Rick, Margie, it's clear that Bobby is extraordinary in both size and strength for his age," I began. "Does he get any supplements from anyone? Specifically, does he take any nutrients or hormones?"

Margie suddenly came alive. "Oh, no, Dr. Castaldo," she assured me, smiling brightly. "Bob's just big from my side of the family. You know, I'm from Montana and we grow 'em big out there!"

"No, no, nothing like that, John," Rick amiably joined in. "Oh, he's taken creatine and high-protein shakes—you know, the usual, perfectly safe, over-the-counter stuff that some people think gives an athlete an edge, but nothing illegal."

These two are smooth, I thought. I needed to get right to the point. "No growth hormone or steroids?"

"Well, he's never taken anabolic steroids," Rick said carefully.

Enough dancing around definitions, I thought impatiently. "So if I were to screen Bobby for drugs, would it be okay with you?" I asked.

Rick straightened up in his seat. "Well, now, I don't think there's any call for that, John," he said. I detected a nervous flutter in his voice. "You know, Bobby's here for the concussion thing, not for drug testing." He ran a hand though his hair. "Now, I'll admit that he takes DHEA regularly, under his family doctor's supervision. But nowadays every kid who's serious about football does that."

Rick was referring to a compound called dehydroepiandrosterone. "DHEA is a steroid that can be converted to testosterone," I said. "It can cause abnormal growth of muscle and bone, agitation, aggressiveness, and other side effects." I looked directly at each of them. "How much does he take?"

Sports like football, in which head impact is a routine part of the game, are increasingly putting protections against second-impact syndrome into their rule books.

"You'd have to ask him that." Rick's voice had turned testy, and Margie was twisting a handkerchief in her lap.

Back in the exam room again with Bobby, I casually asked him about steroids. "I don't take anabolic steroids!" he shot back, his face turning crimson and every muscle in his neck popping with tension.

"Your dad said he thought you might have at one time," I said, pretending to reposition my neurologic instruments on the shelf.

"Well, I don't remember anything about that," he muttered.

"Okay, but if you did take DHEA at one time, how much would you have taken a day, just speaking hypothetically, not for the record, just so I have a better understanding of what some athletes in your position actually take?"

"Two hundred milligrams a day," Bobby responded, without any hesitation.

I let his answer end our exam. I knew that anything more than 25 milligrams was probably too much of this steroid to take safely, even though it was available over the counter. I also knew that steroid use was not the reason Bobby had come in to see me. At this moment, I needed to focus on his neurologic status.

Performing a CT or MRI scan of the brain was considered standard practice for any player who'd suffered potential loss of consciousness during play. I ordered both for Bobby, and the results of both were perfectly normal. But even so, the decision about whether to let him continue to play was an agonizing one.

My review of the medical literature confirmed what I already knew—that there was no universally accepted definition of concussion. But the source that I usually relied on, the American Academy of Neurology (AAN), defined a grade I concussion as one in which the player does not lose consciousness and any symptoms resolve in less than 15 minutes. A grade II concussion involves no loss of consciousness, but symptoms such as confusion, dizziness, or nausea may persist longer than 15 minutes. A grade III concussion is defined as one that produces a loss of consciousness. The AAN suggested that after a grade I concussion an athlete could return to play immediately, while a one-week hiatus was recommended after a grade II concussion and two weeks for grade III.

What wasn't clear from the literature was when to bench someone in Bobby's situation—an athlete who had most likely sustained multiple concussions. One author suggested that after an athlete had sustained three concussions in one season, it could be "appropriate" to sit down with the athlete and the parents and discuss the potential risk of permanent brain injury and consider disqualifying the player from further play. But for how long? A week? A month? The rest of the season? It was entirely up to me to calculate the risks of further serious injury and to make a judgment call.

After further thought and discussion with Bobby, his parents, and his coach, I concluded that those risks were significant and I took Bobby out of play for four weeks.

I did let him return for the latter part of the season, using special equipment designed to better protect his head. Nonetheless, my decision was a highly unpopular one. Everyone protested its necessity and wisdom, especially because it forced Bobby to miss three big games. I scheduled a follow-up visit for Bobby, but he never showed up. In my role as a doctor, I never saw the family again.

Fifteen years later, this case still deeply saddens me. I would like to have freed Bobby Parker from both the assaults on his health and the chains that his sport had cast around his body and his spirit. I would like to have liberated him from the expectations of his father, his coach, and the townspeople who turned out by the thousands for his games, but not so much to see him play as to see him win. During my interview with him, I never got the sense that football was Bobby's true passion, only that of the adults who were invested in his success. I found him to be disturbingly detached and unemotional. Should I have tried to stop the madness?

I also reflect from time to time on the schizophrenic, depressed, delusional man and the other expressions of madness that I saw on the Behavioral Health Unit the day that Bobby's coach called me. While the people there behave bizarrely—tortured as they are by all manner of wild, hallucinatory demons—their particular species of madness had not intimidated me. That's because in the case of these patients, I recognized the underlying diseases that caused their madness and because I was guided in treating them by an established body of knowledge.

Bobby's troubles, however, arose from a wholly different sort of madness. He was the victim of nothing hallucinatory, but rather of sociocultural demons that demand brilliance—perfection, even—from mere children. For these kids failure is not an option, for failure means suffering lacerating disappointment, perhaps even emotional abandonment, from the adults in their lives; such children know this in their blood and in their bones. This kind of madness, a societally sanctioned insanity that plays itself out on athletic fields across the nation, largely escapes detection and is far more difficult to treat.

When I saw Bobby in my office all those years ago, I knew that I wouldn't be able to save him from these demons, and maybe not even from further physical harm. In my heart, I had wanted to disqualify Bobby from play for the rest of the season. But I knew there were plenty of other doctors in town who, if asked for a second opinion, would have promptly put him back in the game. I felt a sense of inevitability about the exam and its outcome that made me feel sick. I was just a hired gun—I'd been asked simply to certify that the boy could play. Bobby Parker's body and talent were far too valuable to be jeopardized by a country neurologist. I know now what his coach and his father meant when they said the consultation was just a formality.

At the time I saw Bobby, I was fairly new to doctoring—in the first decade of my practice in Allentown. Since then, I have learned to be more vigilant about my patients' best interests. I have disqualified a number of young athletes from play because of recurrent concussions, and I'm happy to say that most of my decisions have been made with the blessing of parents and athletes alike. But I have also continued to encounter parents who are pseudo-advocates for their child, and when I do I try to vigorously stand up for these children, who cannot speak for themselves both because of the brainwashing of their sport and their deep desire to please their parents. It has taken me a long time to crack open my own denial and recognize that some parents, astonishingly enough, are willing to sacrifice their children's health and well-being for what they imagine is a higher goal. It is a terrible thing to witness, but I have learned not to turn away from it.

In my heart, I had wanted to disqualify Bobby from play for the rest of the season. But I knew there were plenty of other doctors in town who, if asked for a second opinion, would have promptly put him back in the game. I was just a hired gun—I'd been asked simply to certify that the boy could play.

What happened to Bobby Parker? After he returned to the gridiron that season, his team went on to win the state championship. In his senior year, Bobby won the All Star of the Year award for football and accepted an offer of admission to a prestigious Ivy League college, where he made the varsity in his freshman year. He was written up in our local newspaper as a hometown sports hero, and his father, mother, and coach could not have been prouder.

Epilogue: It has been more than 15 years since I last spoke with that talented, troubled young man. I don't know what he is doing or how he is doing now. What lingers most for me about the few moments I spent in the presence of Bobby Parker—a little boy in a giant man's body—was the profound emptiness I sensed in him. While I did my best to minister to him physically, I sensed that he needed spiritual and emotional healing, too. I didn't see an opening to offer it, but perhaps I didn't try hard enough to make one, either. Even now, all these years later, I am sometimes transported back to that cramped exam room where Bobby and I sat facing each other. I wonder if perhaps, in the spaces and silences of our difficult, halting encounter, I missed an opportunity to make a real difference in Bobby Parker's life.

But I am heartened by the nation's increasing understanding of the damaging effects of both performance-enhancing drugs and second-impact syndrome. There has been significant progress on both fronts as recently as this summer.

Ever since the 1998 Congressional investigation of drug use by Mark McGwire and Sammy Sosa, two of baseball's greatest sluggers, there has been heightened recognition that steroids and growth hormones may build muscle mass, but that they also cause serious health consequences. In August of this year, ace pitcher Roger Clemens—the winner of seven Cy Young Awards, more than any other hurler in history—was indicted by a federal grand jury for lying under oath to Congress, when he testified in 2008, according to Sports Illustrated, that he had "never taken steroids or HGH [human growth hormone]."

I hope that news of this sort, denouncing rather than glorifying drug-enhanced athletic accomplishments, may make today's parents and coaches a little less ready to push such drugs on malleable young players like Bobby Parker.

There has been progress with regard to the problem of head trauma as well. Americans suffer at least 300,000 sports-related brain injuries each year; one study of high-school football players reported that fully 19% had lost consciousness or awareness at least once during the preceding season.

In July of this year, the National Football League produced a poster that, as the New York Times put it, "bluntly alerts its players to the long-term effects of concussions. . . . The poster, soon to be hung in locker rooms league-wide, becomes by far the NFL's most definitive statement on the cognitive risks of football, which it had discredited for most of the past several years as academic studies and reports of deceased players' brain damage mounted."

And in August, a study by researchers at Boston University made national headlines with its conclusion that, as the Los Angeles Times put it, "repeated concussions may contribute to the development of symptoms that mimic amyotrophic lateral sclerosis [ALS], or Lou Gehrig's disease. . . . The suggestion that traumatic brain injuries—also called concussions—may contribute to neurodegenerative disease is not new. But a growing body of research has strengthened evidence that concussion may be the catalyst for a wide range of brain diseases, from depression and dementia to Parkinson's disease symptoms and now . . . ALS."

That suggestion is certainly not new. More than a quarter of a century has passed since Dartmouth's Saunders and Harbaugh first signaled the potential danger of seemingly minor but repeated head trauma. Our understanding of that danger has moved slowly—too slowly to offer much help to the athletes of Bobby Parker's era—but it has moved in the right direction.

Perhaps that's all we can ask for.

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